Provider Demographics
NPI:1093907412
Name:SOUTHEASTERN PEDIATRIC ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:SOUTHEASTERN PEDIATRIC ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:S.
Authorized Official - Middle Name:LUCY
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-794-8656
Mailing Address - Street 1:364 HONEYSUCKLE RD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1140
Mailing Address - Country:US
Mailing Address - Phone:334-794-8656
Mailing Address - Fax:337-702-7047
Practice Address - Street 1:364 HONEYSUCKLE RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1140
Practice Address - Country:US
Practice Address - Phone:334-794-8656
Practice Address - Fax:337-702-7047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272658100Medicaid
AL528300110Medicaid