Provider Demographics
NPI:1912169038
Name:DALE MEDICAL CENTER
Entity Type:Organization
Organization Name:DALE MEDICAL CENTER
Other - Org Name:ANDREW A DUERR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-774-2601
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36361-0460
Mailing Address - Country:US
Mailing Address - Phone:334-445-6329
Mailing Address - Fax:334-445-6001
Practice Address - Street 1:2126 W ROY PARKER RD
Practice Address - Street 2:SUITE 207
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-8566
Practice Address - Country:US
Practice Address - Phone:334-445-6329
Practice Address - Fax:334-445-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25234208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529924880Medicaid
E28521Medicare UPIN