1467783209 NPI number — SOUTHEASTERN MEDICAL COMPOUNDING LLC

Table of content: (NPI 1467783209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467783209 NPI number — SOUTHEASTERN MEDICAL COMPOUNDING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN MEDICAL COMPOUNDING 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:
SOUTHEASTERN MEDICAL COMPOUNDING LLC
Provider Other Organization Name Type Code:
3
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:
1467783209
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7370 HODGSON MEMORIAL DR # C5-B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31406-2536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-401-3234
Provider Business Mailing Address Fax Number:
877-329-0079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 MALL BLVD RM 356B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31406-4805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-201-8138
Provider Business Practice Location Address Fax Number:
877-329-0079
Provider Enumeration Date:
01/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
912-201-8138

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  Y006009 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: PHRE009607 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 2013005924 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 114078 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X , with the licence number: 5301009997 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 264044 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 27038 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: PH25026 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 022297550 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2140641 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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