Provider Demographics
NPI:1619026606
Name:HOUSTON COUNTY HEALTHCARE AUTHORITY
Entity Type:Organization
Organization Name:HOUSTON COUNTY HEALTHCARE AUTHORITY
Other - Org Name:SAMC-ENTERPRISE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:334-793-8087
Mailing Address - Street 1:101 PROFESSIONAL LN
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2085
Mailing Address - Country:US
Mailing Address - Phone:334-347-3404
Mailing Address - Fax:334-393-0613
Practice Address - Street 1:101 PROFESSIONAL LN
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2085
Practice Address - Country:US
Practice Address - Phone:334-347-3404
Practice Address - Fax:334-393-0613
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:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF945OtherBLUE CROSS BLUE SHIELD
ALF134Medicare PIN
ALCG8472Medicare PIN