Basic Information
| Provider Information | |||||||||
| NPI: | 1194763573 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERNCARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHERN CARE LANCASTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 LAKESHORE DR | ||||||||
| Address2: | SUITE 475 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352096705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058684400 | ||||||||
| FaxNumber: | 2058684401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2780 COMMERCE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170573245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179392570 | ||||||||
| FaxNumber: | 7179392573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 12/16/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARDY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2058684400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 16471601 | PA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 1008904340001 | 05 | PA | MEDICAID |