Provider Demographics
NPI:1780776633
Name:MARSHALL MEDICAL CENTER SOUTH
Entity type:Organization
Organization Name:MARSHALL MEDICAL CENTER SOUTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-593-8310
Mailing Address - Street 1:704 MEDICAL CENTER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957
Mailing Address - Country:US
Mailing Address - Phone:256-593-7266
Mailing Address - Fax:256-840-9833
Practice Address - Street 1:704 MEDICAL CENTER PARKWAY
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957
Practice Address - Country:US
Practice Address - Phone:256-593-7266
Practice Address - Fax:256-840-9833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10383207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty