Provider Demographics
NPI:1003190638
Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Other - Org Name:SOUTHEASTERN ANESTHESIOLOGY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5090
Mailing Address - Street 1:300 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3075
Mailing Address - Country:US
Mailing Address - Phone:910-671-5290
Mailing Address - Fax:910-671-8512
Practice Address - Street 1:300 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3075
Practice Address - Country:US
Practice Address - Phone:910-671-5290
Practice Address - Fax:910-671-8512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH0064OtherLICENSE