Provider Demographics
NPI:1184669053
Name:SOUTHEASTERN MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:SOUTHEASTERN MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DABBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-693-1000
Mailing Address - Street 1:PO BOX 636020
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 VANOSDALE RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2497
Practice Address - Country:US
Practice Address - Phone:865-690-3411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3705406Medicaid
TNDD8348OtherRRGA MEDICARE
TN611073900OtherUS DEPT LABOR
TN3705406Medicaid