1356379382 NPI number — SOUTHEASTERN EMERGENCY PHYSICIANS LLC

Table of content: (NPI 1356379382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356379382 NPI number — SOUTHEASTERN EMERGENCY PHYSICIANS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN EMERGENCY PHYSICIANS LLC
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:
SEP
Provider Other Organization Name Type Code:
5
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:
1356379382
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
265 BROOKVIEW CENTRE WAY STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37919-4053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-203-1274
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
989 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAYSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41056-8750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-759-5311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CORVINI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
347-884-1707

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207PP0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0204X ; 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: "N" .
  • Taxonomy code: 291U00000X , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 001740238 . This is a "MOUNTAIN STATES BLUE CROSS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 5C346 . This is a "BS AR" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 3728386 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 507198802 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5901815 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP3694 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157777002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65934218 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4005131000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529931890 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP3965 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 156473002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5902177 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65937690 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017E9 . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 016953800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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