Basic Information
| Provider Information | |||||||||
| NPI: | 1164403861 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOUSTON COUNTY HEALTHCARE AUTHORITY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHEAST HEALTH MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6987 | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363026987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938111 | ||||||||
| FaxNumber: | 3347938779 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 ROSS CLARK CIRCLE | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363013022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938111 | ||||||||
| FaxNumber: | 3347938779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | DEREK | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3347938701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 10358 | AL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 010206700 | 05 | FL | MEDICAID | 000001735A | 05 | GA | MEDICAID | HOS0001H | 05 | AL | MEDICAID | 010057 | 01 | AL | BLUE CROSS | OTHER |