Provider Demographics
NPI:1386679009
Name:SOUTHEASTERN MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:SOUTHEASTERN MEDICAL SUPPLY INC
Other - Org Name:SE MEDICAL SUPPLY
Other - Org Type:Other Name
Authorized Official - Title/Position:SECRETARY/INSURANCE COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:NODELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-233-3691
Mailing Address - Street 1:1024 WILDWOOD CENTRE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8400
Mailing Address - Country:US
Mailing Address - Phone:803-233-3691
Mailing Address - Fax:803-233-6140
Practice Address - Street 1:1024 WILDWOOD CENTRE DR
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-8400
Practice Address - Country:US
Practice Address - Phone:803-233-3691
Practice Address - Fax:803-233-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1386679009332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========OtherTRICARE
SC=========OtherTRICARE