Provider Demographics
NPI:1255876181
Name:HOUSTON COUNTY HEALTHCARE AUTHORITY
Entity type:Organization
Organization Name:HOUSTON COUNTY HEALTHCARE AUTHORITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-793-8111
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:334-678-2895
Practice Address - Street 1:4550 W MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1130
Practice Address - Country:US
Practice Address - Phone:334-446-4700
Practice Address - Fax:334-446-4720
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOUSTON COUNTY HEALTHCARE AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL153687Medicaid
AL102G703993Medicare PIN