1245389303 NPI number — HOUSTON COUNTY HEALTHCARE AUTHORITY

Table of content: (NPI 1245389303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245389303 NPI number — HOUSTON COUNTY HEALTHCARE AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOUSTON COUNTY HEALTHCARE AUTHORITY
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:
SAMC SPECIALTY CLINIC
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:
1245389303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1928
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36302-1928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-793-8087
Provider Business Mailing Address Fax Number:
334-793-8191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4284 KELSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIANNA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32446-2948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-793-8804
Provider Business Practice Location Address Fax Number:
334-699-4473
Provider Enumeration Date:
01/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WOODHAM
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CONTRACT MANAGER
Authorized Official Telephone Number:
334-793-8087

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: OS12208 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 39888B . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 660005100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD1649 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".