Basic Information
Provider Information | |||||||||
NPI: | 1508804279 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERNCARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHERNCARE PETERSBURG | ||||||||
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: | 3321 SOUTH CRATER ROAD | ||||||||
Address2: |   | ||||||||
City: | PETERSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 23805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8047325220 | ||||||||
FaxNumber: | 8047325227 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2006 | ||||||||
LastUpdateDate: | 04/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PARSONS | ||||||||
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 |   | VA | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 010298954 | 05 | VA |   | MEDICAID | HSP-06127 | 01 | VA | STATE LICENSE NUMBER | OTHER |