Provider Demographics
NPI:1033319512
Name:COMMUNITY HEALTHCARE OF DOUGLAS INC
Entity Type:Organization
Organization Name:COMMUNITY HEALTHCARE OF DOUGLAS INC
Other - Org Name:SAMC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:520-364-7931
Mailing Address - Street 1:2174 W OAK AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-6003
Mailing Address - Country:US
Mailing Address - Phone:520-364-7931
Mailing Address - Fax:520-364-2551
Practice Address - Street 1:1906 11TH STREET
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607
Practice Address - Country:US
Practice Address - Phone:520-364-1120
Practice Address - Fax:250-364-6417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH-0015261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ562498Medicaid
AZ562498Medicaid
AZZ116110Medicare PIN