Basic Information
| Provider Information | |||||||||
| NPI: | 1538597349 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOUSTON COUNTY HEALTHCARE AUTHORITY | ||||||||
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| OtherOrganizationName: | SOUTHEAST ALABAMA MEDICAL CENTER MEDICAL CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1928 | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363021928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
| FaxNumber: | 3346782895 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 ROSS CLARK CIR | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363013022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
| FaxNumber: | 3346782895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2013 | ||||||||
| LastUpdateDate: | 12/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | DEREK | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3347938087 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOUSTON COUNTY HEALTHCARE AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 153687 | 05 | AL | MEDICAID | 300041577AH | 05 | GA | MEDICAID |