1467406041 NPI number — SOUTHEASTERN ORTHOPAEDICS

Table of content: (NPI 1467406041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467406041 NPI number — SOUTHEASTERN ORTHOPAEDICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN ORTHOPAEDICS
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:
1467406041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
760 N NEW HOPE RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
GASTONIA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-866-8976
Provider Business Mailing Address Fax Number:
704-866-8680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
760 N NEW HOPE RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-866-8976
Provider Business Practice Location Address Fax Number:
704-866-8680
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCMAHAN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
704-866-8976

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  320 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 014C3 . This is a "BCBS INDIVIDUAL" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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