Provider Demographics
NPI:1275591851
Name:SOUTHEAST SURGICAL, PLLC
Entity Type:Organization
Organization Name:SOUTHEAST SURGICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:JEFFERSON
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-424-9069
Mailing Address - Street 1:1265 E COLLEGE ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-4541
Mailing Address - Country:US
Mailing Address - Phone:931-424-9069
Mailing Address - Fax:931-424-9079
Practice Address - Street 1:1265 E COLLEGE ST
Practice Address - Street 2:SUITE 9
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4541
Practice Address - Country:US
Practice Address - Phone:931-424-9069
Practice Address - Fax:931-424-9079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39634208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729797Medicare ID - Type UnspecifiedGROUP MEDICARE