Provider Demographics
NPI:1053592295
Name:MONROE COUNTY HEALTH CARE AUTHORITY
Entity type:Organization
Organization Name:MONROE COUNTY HEALTH CARE AUTHORITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:NALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-743-7430
Mailing Address - Street 1:P.O. BOX 886
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36460
Mailing Address - Country:US
Mailing Address - Phone:251-575-3111
Mailing Address - Fax:251-743-7445
Practice Address - Street 1:1075 DREWRY ROAD
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36460
Practice Address - Country:US
Practice Address - Phone:251-575-3111
Practice Address - Fax:251-743-7445
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONROE COUNTY HEALTH CARE AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-15
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL207Q00000X
IN207Q00000X
207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529911710Medicaid
AL529911710Medicaid
=========011OtherCHAMPUS GROUP PROVIDER NO