1184669053 NPI number — SOUTHEASTERN MEDICAL GROUP, PC

Table of content: DR. BEN U. MARSAN M.D. (NPI 1518977479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184669053 NPI number — SOUTHEASTERN MEDICAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN MEDICAL GROUP, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184669053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636020
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-6020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREVARD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28712-3378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-884-9111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DABBS
Authorized Official First Name:
RANDAL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
865-693-1000

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1184669053 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3705406 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD8348 . This is a "RRGA MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 611073900 . This is a "US DEPT LABOR" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".