1083721732 NPI number — SOUTHERN HEALTH CORP. OF HOUSTON, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083721732 NPI number — SOUTHERN HEALTH CORP. OF HOUSTON, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN HEALTH CORP. OF HOUSTON, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY MEDICAL CLINIC OF HOUSTON
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083721732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 432
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38851-0432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-456-5008
Provider Business Mailing Address Fax Number:
662-456-5404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 E MADISON ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38851-2428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-456-5008
Provider Business Practice Location Address Fax Number:
662-456-5404
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROCKMAN
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
662-456-3700

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  12-296 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09014528 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: C02044 . This is a "MEDICARE PART B GROUP" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 253422 . This is a "TRISPAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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