Provider Demographics
NPI:1043220585
Name:SOUTHEAST ALABAMA RURAL HEALTH ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHEAST ALABAMA RURAL HEALTH ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAMYLON
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-670-6726
Mailing Address - Street 1:1414 ELBA HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-6020
Mailing Address - Country:US
Mailing Address - Phone:334-670-6726
Mailing Address - Fax:334-670-6731
Practice Address - Street 1:1414 ELBA HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36079-6020
Practice Address - Country:US
Practice Address - Phone:334-670-6726
Practice Address - Fax:334-670-6731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630000018Medicaid