1871735019 NPI number — SOUTHEASTERN REGIONAL MEDICAL CENTER

Table of content: (NPI 1871735019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871735019 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:
SRMC-AUDIOLOGY
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:
1871735019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 890860
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28289-0860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-671-5000
Provider Business Mailing Address Fax Number:
910-608-0269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
584 FARRINGDOM ST
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:
28358-2615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-671-5014
Provider Business Practice Location Address Fax Number:
910-608-0269
Provider Enumeration Date:
04/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
910-671-5090

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X , with the licence number:  H0064 , 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)

  • Identifier: 7200273 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3404235 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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