Provider Demographics
NPI:1043852601
Name:SOUTHEASTERN CENTER FOR FERTILITY AND REPRODUCTIVE SURGERY, PLLC
Entity Type:Organization
Organization Name:SOUTHEASTERN CENTER FOR FERTILITY AND REPRODUCTIVE SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-777-0088
Mailing Address - Street 1:PO BOX 25686
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2007
Mailing Address - Country:US
Mailing Address - Phone:617-402-1000
Mailing Address - Fax:617-402-1099
Practice Address - Street 1:11126 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2806
Practice Address - Country:US
Practice Address - Phone:865-777-0088
Practice Address - Fax:865-777-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Single Specialty