Provider Demographics
NPI:1144388174
Name:SOUTHEASTERN SURGICAL CENTER
Entity Type:Organization
Organization Name:SOUTHEASTERN SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:H RON
Authorized Official - Middle Name:H
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-459-3473
Mailing Address - Street 1:1100 JOHNSON FERRY ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-257-1900
Mailing Address - Fax:404-257-0792
Practice Address - Street 1:1100 JOHNSON FERRY ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-257-1900
Practice Address - Fax:404-257-0792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA060079OtherPERMIT