Basic Information
| Provider Information | |||||||||
| NPI: | 1295065811 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOUSTON COUNTY HEALTHCARE AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TROY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1928 | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363021928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
| FaxNumber: | 3347938191 | ||||||||
| Practice Location | |||||||||
| Address1: | 889 ELBA HWY | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360796017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343473404 | ||||||||
| FaxNumber: | 3343930613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2010 | ||||||||
| LastUpdateDate: | 01/04/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | DEREK | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3347938111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOUSTON COUNTY HEALTHCARE AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.