Provider Demographics
NPI:1700081254
Name:DALE MEDICAL CENTER
Entity Type:Organization
Organization Name:DALE MEDICAL CENTER
Other - Org Name:DMC ANESTHESIA
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-774-2601
Mailing Address - Street 1:PO BOX 863
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36361-0863
Mailing Address - Country:US
Mailing Address - Phone:334-443-1211
Mailing Address - Fax:334-443-0131
Practice Address - Street 1:126 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-2018
Practice Address - Country:US
Practice Address - Phone:334-774-2601
Practice Address - Fax:334-774-8863
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DALE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-15
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALW090OtherBCBS COMMON PAY NUMBER
AL529908650Medicaid
AL529908650Medicaid