Provider Demographics
NPI:1083835441
Name:SOUTHEASTERN PHYSICIAN SERVICES PC
Entity Type:Organization
Organization Name:SOUTHEASTERN PHYSICIAN SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DABBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-203-1274
Mailing Address - Street 1:PO BOX 635705
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5705
Mailing Address - Country:US
Mailing Address - Phone:888-203-1274
Mailing Address - Fax:
Practice Address - Street 1:990 OAK RIDGE TPKE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6976
Practice Address - Country:US
Practice Address - Phone:865-481-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207R00000X, 208M00000X, 363A00000X, 363L00000X
207X00000X, 261QM0850X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370208Medicaid
SCGP5012Medicaid
KY7100046370Medicaid
AL529932974Medicaid
NC5950338Medicaid
TN3370208Medicaid
TN3370208Medicare PIN
AL529932974Medicaid
SCGP5012Medicaid