Provider Demographics
NPI:1134665789
Name:SOUTHEAST PRIMARY CARE, PLLC
Entity Type:Organization
Organization Name:SOUTHEAST PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:RODERIC
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:828-230-5915
Mailing Address - Street 1:2007 PATAPSCO DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27523-3922
Mailing Address - Country:US
Mailing Address - Phone:828-230-5915
Mailing Address - Fax:
Practice Address - Street 1:1911 FALLS VALLEY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-2495
Practice Address - Country:US
Practice Address - Phone:919-249-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty