Provider Demographics
NPI:1073697553
Name:SOUTHEAST RENAL ASSOCIATES PA
Entity Type:Organization
Organization Name:SOUTHEAST RENAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNEYCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-927-1755
Mailing Address - Street 1:2301 W MOREHEAD ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5178
Mailing Address - Country:US
Mailing Address - Phone:704-333-4217
Mailing Address - Fax:704-927-1767
Practice Address - Street 1:2301 W MOREHEAD ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5178
Practice Address - Country:US
Practice Address - Phone:704-333-4217
Practice Address - Fax:704-927-1767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0109VOtherBCBS OF NC
SCNPA650Medicaid
NC890109VMedicaid
NC=========OtherCIGNA
NC=========OtherPARTNERS
NC890109VMedicaid
SC8481Medicare ID - Type UnspecifiedSC MEDICARE
SCNPA650Medicaid
NC890109VMedicaid