Provider Demographics
NPI:1922234467
Name:EVERGREEN BREWTON MEDICAL, INC.
Entity Type:Organization
Organization Name:EVERGREEN BREWTON MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-809-8398
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36427-0190
Mailing Address - Country:US
Mailing Address - Phone:251-867-8001
Mailing Address - Fax:251-867-9643
Practice Address - Street 1:103 ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1336
Practice Address - Country:US
Practice Address - Phone:251-867-8001
Practice Address - Fax:251-867-9643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13720208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty