1356543383 NPI number — SOUTHEASTERN REGIONAL MEDICAL CENTER

Table of content: ANDREA ROSE DURANTE PHYSICAL THERAPIST (NPI 1629494307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356543383 NPI number — SOUTHEASTERN REGIONAL MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN REGIONAL MEDICAL CENTER
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:
1356543383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1031 GATESVILLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOPE MILLS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28348-8001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-426-9346
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4895 FAYETTEVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUMBERTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28358-2162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-738-4554
Provider Business Practice Location Address Fax Number:
910-739-4027
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NICOSIA
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
910-738-4554

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  8799 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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