1104847607 NPI number — SOUTHEAST INTERNAL MEDICINE PC

Table of content: (NPI 1104847607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104847607 NPI number — SOUTHEAST INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST INTERNAL MEDICINE PC
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:
1104847607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 777
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYCROSS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31502-0777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-287-1555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 RIVERSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31501-5315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-287-1555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BELLECCI
Authorized Official First Name:
PAULINE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
912-287-1555

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GRP642 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: CC4999 . This is a "PALMETTO GBA MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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