NPIMap

Organization Active NPI

Southern Clinic PC

  • Internal Medicine Physician
  • Dothan, AL
National Provider Identifier
1053410480
Registry record updated Feb 1, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
SOUTHERN CLINIC PC
Practice address
1901 Melba Dr
Dothan, AL 36301-3017
Phone
(334) 794-6611
Fax
(334) 794-6614
NPI assigned
Sep 22, 2006
Last updated
Feb 1, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 1, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Brian Holman
Title
Office Administrator
Phone
(334) 794-6611

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Nurse Practitioner 363L00000X
Internal Medicine Physician 207R00000X Primary

Addresses

Primary practice location

1901 Melba Dr
Dothan, AL 36301-3017

Mailing address

1901 Melba Dr
Dothan, AL 36301-3017
Phone (334) 794-6611

Other identifiers 1

IdentifierTypeStateIssuer
Q684OtherALBC/BS OF ALABAMA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL, FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040708000585 AL Part B Supplier - Clinic/Group Practice 1355329269 Receives reassigned benefits from 30 practitioners
Practice locations: Dothan, AL
O20110627000171 FL Part B Supplier - Clinic/Group Practice 1355329269 Receives reassigned benefits from 1 practitioner
Practice locations: Graceville, FL

National Provider Directory

National Provider Directory

Locations

1901 Melba Dr
Dothan, AL 36301
Phone (334) 793-6411

201 Doctors Dr
Dothan, AL 36301
Phone (334) 794-6611

Interoperability endpoints

  • FHIR API: https://fhir-api.fhirprod.aws.greenwayhealth.com/fhir/R4/2.16.840.1.113883.3.441.1720

Practitioners & affiliated clinicians

Practitioners 30

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 30

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158883200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1201824000000",
    "number": "1053410480",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1901 MELBA DR",
            "city": "DOTHAN",
            "state": "AL",
            "postal_code": "363013017",
            "telephone_number": "334-794-6611",
            "fax_number": "334-794-6614"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1901 MELBA DR",
            "city": "DOTHAN",
            "state": "AL",
            "postal_code": "363013017",
            "telephone_number": "334-794-6611",
            "fax_number": "334-794-6614"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN CLINIC PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-22",
        "last_updated": "2008-02-01",
        "status": "A",
        "authorized_official_last_name": "HOLMAN",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_title_or_position": "OFFICE ADMINISTRATOR",
        "authorized_official_telephone_number": "334-794-6611",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BC/BS OF ALABAMA",
            "identifier": "Q684",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Dothan, AL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 1, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.