Provider Demographics
NPI:1093729386
Name:SOUTHEASTERN MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NOWAMAGBE
Authorized Official - Middle Name:A
Authorized Official - Last Name:OMOIGUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-957-0770
Mailing Address - Street 1:609 SOUTH LAKE DR
Mailing Address - Street 2:STE 1
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-4119
Mailing Address - Country:US
Mailing Address - Phone:803-957-0770
Mailing Address - Fax:803-957-0909
Practice Address - Street 1:609 SOUTH LAKE DR
Practice Address - Street 2:STE 1
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-4119
Practice Address - Country:US
Practice Address - Phone:803-957-0770
Practice Address - Fax:803-957-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17764174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1386645596OtherDR. OMOIGUI IND NPI #
SC17764OtherSC MEDICAL LICENSE #
SC$$$$$$$$$OtherDR. OMOIGUI SSN