Provider Demographics
NPI:1164403861
Name:HOUSTON COUNTY HEALTHCARE AUTHORITY
Entity Type:Organization
Organization Name:HOUSTON COUNTY HEALTHCARE AUTHORITY
Other - Org Name:SOUTHEAST HEALTH MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-793-8701
Mailing Address - Street 1:PO BOX 6987
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-6987
Mailing Address - Country:US
Mailing Address - Phone:334-793-8111
Mailing Address - Fax:334-793-8779
Practice Address - Street 1:1108 ROSS CLARK CIRCLE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3022
Practice Address - Country:US
Practice Address - Phone:334-793-8111
Practice Address - Fax:334-793-8779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10358282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010206700Medicaid
GA000001735AMedicaid
ALHOS0001HMedicaid
AL010057OtherBLUE CROSS
AL010057OtherBLUE CROSS