Provider Demographics
NPI:1073015095
Name:SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Entity Type:Organization
Organization Name:SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Other - Org Name:MEADOWS MEDICAL GROUP GENERAL AND VASCULAR SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:O'STEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-535-5560
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-535-5560
Mailing Address - Fax:
Practice Address - Street 1:303 HARRIS INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8853
Practice Address - Country:US
Practice Address - Phone:912-538-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty