1083074314 NPI number — SOUTHEASTERN MEDICAL GROUP, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083074314 NPI number — SOUTHEASTERN MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN MEDICAL GROUP, INC
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:
1083074314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1881 NE 26TH ST
Provider Second Line Business Mailing Address:
SUITE 224
Provider Business Mailing Address City Name:
WILTON MANORS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33305-1416
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:
1881 NE 26TH ST
Provider Second Line Business Practice Location Address:
SUITE 224
Provider Business Practice Location Address City Name:
WILTON MANORS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33305-1416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-398-1947
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ZERVOUDAKIS
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
MILENA
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
954-398-1947

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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