Provider Demographics
NPI:1245389303
Name:HOUSTON COUNTY HEALTHCARE AUTHORITY
Entity Type:Organization
Organization Name:HOUSTON COUNTY HEALTHCARE AUTHORITY
Other - Org Name:SAMC SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:WOODHAM
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:334-793-8087
Mailing Address - Street 1:PO BOX 1928
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1928
Mailing Address - Country:US
Mailing Address - Phone:334-793-8087
Mailing Address - Fax:334-793-8191
Practice Address - Street 1:4284 KELSON AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2948
Practice Address - Country:US
Practice Address - Phone:334-793-8804
Practice Address - Fax:334-699-4473
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOUSTON COUNTY HEALTHCARE AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-09
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363L00000X
FLOS12208207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39888BOtherBLUE CROSS BLUE SHIELD
FL660005100Medicaid
DD1649OtherRAILROAD MEDICARE
FL39888BOtherBLUE CROSS BLUE SHIELD
FL108943Medicare Oscar/Certification