1093729386 NPI number — SOUTHEASTERN MEDICAL GROUP, LLC

Table of content: (NPI 1093729386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093729386 NPI number — SOUTHEASTERN MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN MEDICAL GROUP, 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:
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:
1093729386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
609 SOUTH LAKE DR
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29072-4119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-957-0770
Provider Business Mailing Address Fax Number:
803-957-0909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 SOUTH LAKE DR
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29072-4119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-957-0770
Provider Business Practice Location Address Fax Number:
803-957-0909
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OMOIGUI
Authorized Official First Name:
NOWAMAGBE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
803-957-0770

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  17764 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1386645596 . This is a "DR. OMOIGUI IND NPI #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 17764 . This is a "SC MEDICAL LICENSE #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: $$$$$$$$$ . This is a "DR. OMOIGUI SSN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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