1427282045 NPI number — SOUTHEASTERN REGIONAL PHYSICIAN SERVICES

Table of content: (NPI 1427282045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427282045 NPI number — SOUTHEASTERN REGIONAL PHYSICIAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
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:
1427282045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2002 N CEDAR ST STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUMBERTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28358-3926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-272-3048
Provider Business Mailing Address Fax Number:
910-738-3764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2002 N CEDAR ST STE B
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:
28358-3926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-272-3048
Provider Business Practice Location Address Fax Number:
910-738-3764
Provider Enumeration Date:
05/11/2009

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: 261QM1300X , with the licence number:  H0064 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X , with the licence number: H0064 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 022WP . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 022WT . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 023R1 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 344638C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344641A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5917766 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344639A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344642A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5914045 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5921524 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348954A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348954C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348961C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5914044 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5917135 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5918279 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344639C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344642C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5914043 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5914048 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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