MEDICARE: SOUTHERN MEDICAL HOLDINGS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	DO639	AL

General Provider Information

NPI Number	:	1881073294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN MEDICAL HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	190 INDEPENDENT DR STE A
Second Line	:
City	:	RAINBOW CITY
State	:	AL
Zip	:	35906-3286
Country	:	US
Telephone Number	:	256-442-1834
Fax Number	:	877-991-4819

Provider Business Practice Location Address
First Line	:	190 INDEPENDENT DR STE A
Second Line	:
City	:	RAINBOW CITY
State	:	AL
Zip	:	35906-3286
Country	:	US
Telephone Number	:	256-442-1834
Fax Number	:	877-991-4819

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN MATTOX RAINES
Credential	:	D.O.
Telephone Number	:	256-442-1834

Provider Enumeration Date	:	05/19/2015
Last Update Date	:	08/31/2021

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