Provider Demographics
NPI:1114953742
Name:SOUTHEAST WOUND SPECIALISTS, LLC
Entity Type:Organization
Organization Name:SOUTHEAST WOUND SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-232-9700
Mailing Address - Street 1:PO BOX 1345
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31402-1345
Mailing Address - Country:US
Mailing Address - Phone:912-232-9700
Mailing Address - Fax:912-748-0270
Practice Address - Street 1:9302 MEDIAL PLAZA DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9142
Practice Address - Country:US
Practice Address - Phone:912-232-9700
Practice Address - Fax:912-748-0270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4454Medicaid
GA013997Medicaid