Provider Demographics
NPI:1881073294
Name:SOUTHERN MEDICAL HOLDINGS, LLC
Entity type:Organization
Organization Name:SOUTHERN MEDICAL HOLDINGS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MATTOX
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:256-442-1834
Mailing Address - Street 1:190 INDEPENDENT DR STE A
Mailing Address - Street 2:
Mailing Address - City:RAINBOW CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35906-3286
Mailing Address - Country:US
Mailing Address - Phone:256-442-1834
Mailing Address - Fax:877-991-4819
Practice Address - Street 1:190 INDEPENDENT DR STE A
Practice Address - Street 2:
Practice Address - City:RAINBOW CITY
Practice Address - State:AL
Practice Address - Zip Code:35906-3286
Practice Address - Country:US
Practice Address - Phone:256-442-1834
Practice Address - Fax:877-991-4819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO639261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH09811Medicare UPIN