Provider Demographics
NPI:1205866274
Name:SOUTHEASTERN VASCULAR, P.C.
Entity Type:Organization
Organization Name:SOUTHEASTERN VASCULAR, P.C.
Other - Org Name:SOUTHEASTERN SURGICAL ASSOCIATES PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLINWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-775-1984
Mailing Address - Street 1:100 CAMP ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3007
Mailing Address - Country:US
Mailing Address - Phone:508-775-1984
Mailing Address - Fax:508-790-1897
Practice Address - Street 1:100 CAMP ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3007
Practice Address - Country:US
Practice Address - Phone:508-775-1984
Practice Address - Fax:508-790-1897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9776605Medicaid
MASOM16224OtherBCBS
MA9776605Medicaid