Provider Demographics
NPI:1235417288
Name:SOUTHEASTERN REGIONAL MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL MEDICAL CENTER, INC.
Other - Org Name:SOUTHEASTERN REGIONAL MEDICAL CENTER, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:700-400-6080
Mailing Address - Street 1:2610 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-2615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 CELEBRATE LIFE PARKWAY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8000
Practice Address - Country:US
Practice Address - Phone:404-844-8334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-25
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136026AMedicaid