Basic Information
Provider Information | |||||||||
NPI: | 1326072646 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERNCARE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHERNCAREJASPER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2204 LAKESHORE DR | ||||||||
Address2: | SUITE 475 | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352096705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2058684400 | ||||||||
FaxNumber: | 2058684401 | ||||||||
Practice Location | |||||||||
Address1: | 4330 HIGHWAY 78 E | ||||||||
Address2: | SUITE 210 & 211 | ||||||||
City: | JASPER | ||||||||
State: | AL | ||||||||
PostalCode: | 355018905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2053870249 | ||||||||
FaxNumber: | 2053870681 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2006 | ||||||||
LastUpdateDate: | 04/27/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PARSONS | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2058684400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 11076 | AL | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | PIC1625E | 05 | AL |   | MEDICAID |