Provider Demographics
NPI:1386037539
Name:SOUTHEASTERN HEALTH PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SOUTHEASTERN HEALTH PHYSICIAN SERVICES
Other - Org Name:SOUTHEASTERN MEDICAL CLINIC WHITE LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FORDHAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5026
Mailing Address - Street 1:1921 WHITE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-6236
Mailing Address - Country:US
Mailing Address - Phone:910-862-6491
Mailing Address - Fax:910-862-7641
Practice Address - Street 1:1921 WHITE LAKE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-6236
Practice Address - Country:US
Practice Address - Phone:910-862-6491
Practice Address - Fax:910-862-7641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty