Provider Demographics
NPI:1083074314
Name:SOUTHEASTERN MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SOUTHEASTERN MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:MILENA
Authorized Official - Last Name:ZERVOUDAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:954-398-1947
Mailing Address - Street 1:1881 NE 26TH ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1881 NE 26TH ST
Practice Address - Street 2:SUITE 224
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1416
Practice Address - Country:US
Practice Address - Phone:954-398-1947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty