Provider Demographics
NPI:1013937705
Name:MIZELL MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:MIZELL MEMORIAL HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:334-493-9111
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:OPP
Mailing Address - State:AL
Mailing Address - Zip Code:36467-1010
Mailing Address - Country:US
Mailing Address - Phone:334-493-3541
Mailing Address - Fax:334-493-3789
Practice Address - Street 1:702 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OPP
Practice Address - State:AL
Practice Address - Zip Code:36467-1626
Practice Address - Country:US
Practice Address - Phone:334-493-3541
Practice Address - Fax:334-493-9433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QL0400X
AL273R00000X, 275N00000X
AL11789282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsy
No273R00000XHospital UnitsPsychiatric Unit
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALHOS0007HMedicaid
AL010095OtherBLUE CROSS BLUE SHIELD
AL010095OtherBLUE CROSS BLUE SHIELD
AL010007Medicare Oscar/Certification
AL01S007Medicare Oscar/Certification
AL01U007Medicare Oscar/Certification