1427081934 NPI number — SOUTHEAST MEDICAL, INC.

Table of content: (NPI 1427081934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427081934 NPI number — SOUTHEAST MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST MEDICAL, 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:
6
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:
1427081934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 674553
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48267-4553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-707-8807
Provider Business Mailing Address Fax Number:
772-212-4904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 N MAIN ST STE 229
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAYTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30525-4264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-707-8807
Provider Business Practice Location Address Fax Number:
772-212-4904
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VESTAL
Authorized Official First Name:
EMILY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT AND DIRECTOR
Authorized Official Telephone Number:
866-897-8588

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: EN2129-CLTC , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1519605 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7705428 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 893856568A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 893856568B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE2802 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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