NPIMap

Organization Active NPI

Mizell Memorial Hospital, Inc.

Doing business as Elba Healthcare

  • Family Medicine Physician
  • Elba, AL
National Provider Identifier
1033863170
Registry record updated Feb 8, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
MIZELL MEMORIAL HOSPITAL, INC.
Doing business as
Elba Healthcare
Practice address
918 Drayton Ave
Elba, AL 36323-1448
Phone
(334) 493-5713
NPI assigned
Feb 8, 2022
Last updated
Feb 8, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
MIZELL MEMORIAL HOSPITAL, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 8, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jana Wyatt
Title
Cfo
Phone
(334) 493-5790

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

918 Drayton Ave
Elba, AL 36323-1448

Mailing address

PO Box 1010
Opp, AL 36467-1010
Phone (334) 493-5713

Other names 1

  • Elba Healthcare Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220517000763 AL Part A Provider - Rural Health Clinic 6507820990 Practice locations: Elba, AL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1033863170. Details of each certification follow.

Rural health clinic certification: CCN 018501

Legal name
MIZELL MEMORIAL HOSPITAL, INC.
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 25, 2023
Last certification
Jan 25, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Nov 26, 1945 in AL
Enrollment address
918 Drayton Ave
Elba, AL 36323-1448
Related CCNs
010007

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Andy Kirk MD5 organizations share this tax ID, including this one
Part of
Andy Kirk MD

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

511 Brantley St
Opp, AL 36467
Phone (334) 493-3240

802 N Main St
Opp, AL 36467
Phone (334) 493-3240

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jana Wyatt Individual Corporate OfficerCeo/Cfo May 25, 2005
Amanda Dianne Daugherty Individual W-2 Managing EmployeeDirector Patient Accounting Mar 1, 2021
OtherDirector Patient Accounting Mar 1, 2021

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Mizell Memorial Hospital, Inc.Opp, AL, CCN 01U007 Hospital Other Nov 29, 1945
Mizell Memorial Hospital, Inc.Opp, AL, CCN 010007 Hospital Other Nov 29, 1945
Mizell Memorial Hospital, Inc.Opp, AL, CCN 01S007 Hospital Other Nov 29, 1945
LHC Homecare of South AlabamaOpp, AL, CCN 017134 Home health agency 5% Or Greater Direct Ownership Interest (10%) Jan 17, 2005

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 20

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 20

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1644278400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1644278400000",
    "number": "1033863170",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1010",
            "city": "OPP",
            "state": "AL",
            "postal_code": "364671010",
            "telephone_number": "334-493-5713"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "918 DRAYTON AVE",
            "city": "ELBA",
            "state": "AL",
            "postal_code": "363231448",
            "telephone_number": "334-493-5713"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIZELL MEMORIAL HOSPITAL, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MIZELL MEMORIAL HOSPITAL, INC.",
        "enumeration_date": "2022-02-08",
        "last_updated": "2022-02-08",
        "certification_date": "2022-02-08",
        "status": "A",
        "authorized_official_last_name": "WYATT",
        "authorized_official_first_name": "JANA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "334-493-5790"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Elba Healthcare",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Elba, AL

Sources for this page

Verify at the official NPI Registry.