1689656522 NPI number — MED-SOUTH, INC.

Table of content: (NPI 1689656522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689656522 NPI number — MED-SOUTH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED-SOUTH, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY MEDICAL STORE, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689656522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35501-3400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-221-8200
Provider Business Mailing Address Fax Number:
205-221-8270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2330 US HIGHWAY 431
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOAZ
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35957-5905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-593-0677
Provider Business Practice Location Address Fax Number:
256-593-0658
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PACE
Authorized Official First Name:
STEWART
Authorized Official Middle Name:
H
Authorized Official Title or Position:
SR VICE PRESIDENT OF CORPORATE DEVE
Authorized Official Telephone Number:
205-414-7525

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  188 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332BX2000X , with the licence number: 900493 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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