Basic Information
| Provider Information | |||||||||
| NPI: | 1164705380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PICKENS COUNTY MEDICAL CENTER,INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 241 ROBERT K WILSON DR | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354470478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053672408 | ||||||||
| FaxNumber: | 2053672121 | ||||||||
| Practice Location | |||||||||
| Address1: | 241 ROBERT K WILSON DR | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354470478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053672408 | ||||||||
| FaxNumber: | 2053672121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2011 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | MCELROY | ||||||||
| AuthorizedOfficialFirstName: | H | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2053678111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PICKENS COUNTY MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | H5401 | AL | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 1164423679 | 01 | MEDICARE NPI | OTHER | 47910905 | 05 | AL | MEDICAID |