Provider Demographics
NPI:1306010558
Name:SOUTHEASTERN CARDIOLOGY PA
Entity Type:Organization
Organization Name:SOUTHEASTERN CARDIOLOGY PA
Other - Org Name:BLADENBORO FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:ROYAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-671-6177
Mailing Address - Street 1:2610 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3011
Mailing Address - Country:US
Mailing Address - Phone:910-671-6177
Mailing Address - Fax:910-671-6175
Practice Address - Street 1:2610 N ELM ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3011
Practice Address - Country:US
Practice Address - Phone:910-671-6177
Practice Address - Fax:910-671-6177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2344619OtherMEDICARE