1194763573 NPI number — SOUTHERNCARE INC

Table of content: (NPI 1194763573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194763573 NPI number — SOUTHERNCARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERNCARE 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:
Provider Other Organization Name Type Code:
6
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:
1194763573
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2204 LAKESHORE DR
Provider Second Line Business Mailing Address:
SUITE 475
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35209-6705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-868-4400
Provider Business Mailing Address Fax Number:
205-868-4401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2780 COMMERCE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17057-3245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-939-2570
Provider Business Practice Location Address Fax Number:
717-939-2573
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PARDY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO PRESIDENT
Authorized Official Telephone Number:
205-868-4400

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  16471601 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1008904340001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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