NPIMap

Organization Active NPI

Mizell Memorial Hospital, Inc.

  • Family Medicine Physician
  • Opp, AL
National Provider Identifier
1760728455
Registry record updated Jan 14, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
MIZELL MEMORIAL HOSPITAL, INC.
Practice address
802 N Main St
Opp, AL 36467-1614
Phone
(334) 493-3240
Fax
(334) 493-9535
NPI assigned
Dec 27, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 14, 2021

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

Authorized official

Name
Jana Wyatt
Title
Ceo
Phone
(334) 493-9111

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

802 N Main St
Opp, AL 36467-1614

Mailing address

PO Box 1010
Opp, AL 36467-1010
Phone (334) 493-3541

Other identifiers 1

IdentifierTypeStateIssuer
144655MedicaidAL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20051220000136 AL Part B Supplier - Clinic/Group Practice 6507820990 Receives reassigned benefits from 19 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Opp, AL
O20200305001882 AL Part A Provider - Rural Health Clinic 6507820990 Practice locations: Opp, AL

Rural health clinic certification: CCN 013488

Legal name
MIZELL MEMORIAL HOSPITAL, INC.
Doing business as
MIZELL MEMORIAL MEDICAL CLINIC 1
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 3, 2020
Last certification
Jul 31, 2020
Ownership / control type
2B
Organization structure
OtherNon-profit
Incorporated
Nov 26, 1945 in AL
Enrollment address
802 N Main St
Opp, AL 36467-1632
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).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
01D2053453Mizell Memorial Medical Clinic802 N Main Street, Opp, AL 36467Certificate of waiverJan 30, 2027

National Provider Directory

National Provider Directory

Locations

702 N Main St
Fl 2
Opp, AL 36467

702 N Main St
#2
Opp, AL 36467

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
John Adams Individual Corporate DirectorVice-Chairman Jul 1, 2016
Frank L McGuire Individual Corporate DirectorSecretary Sep 1, 2017
Jonathan M Stanfield Individual Corporate DirectorBoard of Directors Aug 1, 2016
Melinda Hall Individual Corporate DirectorBoard of Directors Sep 1, 2017
Skipper Spurlin Individual Corporate DirectorBoard of Directors Sep 1, 2017
Steven J Davis Individual Corporate DirectorBoard of Directors Oct 1, 2019
Jana Wyatt Individual Corporate OfficerCeo/Cfo Jan 10, 2020
W-2 Managing EmployeeCeo/Cfo Jan 10, 2020
Joshua J. Driver Individual Corporate DirectorBoard of Directors Dec 1, 2019
Jeffrey Harold Worley Individual Corporate DirectorChairman Sep 1, 2019
Donna Youmans Individual Corporate DirectorBoard of Directors Apr 1, 2016

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

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 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1356566400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1610582400000",
    "number": "1760728455",
    "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": "334-493-3541",
            "fax_number": "334-493-9664"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "802 N MAIN ST",
            "city": "OPP",
            "state": "AL",
            "postal_code": "364671614",
            "telephone_number": "334-493-3240",
            "fax_number": "334-493-9535"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIZELL MEMORIAL HOSPITAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-12-27",
        "last_updated": "2021-01-14",
        "certification_date": "2021-01-14",
        "status": "A",
        "authorized_official_last_name": "WYATT",
        "authorized_official_first_name": "JANA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "334-493-9111"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "144655",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Opp, AL

Sources for this page

Verify at the official NPI Registry.