1578975611 NPI number — SOUTHEASTERN REGIONAL PHYSICIAN SERVICES

Table of content: (NPI 1578975611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578975611 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:
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:
1578975611
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:
4901 DAWN DR
Provider Second Line Business Practice Location Address:
3RD FLOOR SUITE 1
Provider Business Practice Location Address City Name:
LUMBERTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28360-8207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-735-2830
Provider Business Practice Location Address Fax Number:
910-735-2832
Provider Enumeration Date:
05/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BRITT
Authorized Official First Name:
FORDHAM
Authorized Official Middle Name:
B
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
910-671-5026

Provider Taxonomy Codes

  • Taxonomy code: 2081N0008X , with the licence number:  H0064 , 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)





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