Provider Demographics
NPI:1508804279
Name:SOUTHERNCARE INC
Entity Type:Organization
Organization Name:SOUTHERNCARE INC
Other - Org Name:SOUTHERNCARE PETERSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARSONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-868-4400
Mailing Address - Street 1:2204 LAKESHORE DR
Mailing Address - Street 2:SUITE 475
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-6705
Mailing Address - Country:US
Mailing Address - Phone:205-868-4400
Mailing Address - Fax:205-868-4401
Practice Address - Street 1:3321 SOUTH CRATER ROAD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805
Practice Address - Country:US
Practice Address - Phone:804-732-5220
Practice Address - Fax:804-732-5227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010298954Medicaid
VAHSP-06127OtherSTATE LICENSE NUMBER
491583Medicare Oscar/Certification