Provider Demographics
NPI:1437338571
Name:SOUTHEASTERN ORTHOPAEDIC SPECIALISTS
Entity Type:Organization
Organization Name:SOUTHEASTERN ORTHOPAEDIC SPECIALISTS
Other - Org Name:SPORTS MEDICINE AND ORTHOPAEDIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-275-6318
Mailing Address - Street 1:209 LINDSAY ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4853
Mailing Address - Country:US
Mailing Address - Phone:336-887-8400
Mailing Address - Fax:336-887-3013
Practice Address - Street 1:209 LINDSAY ST
Practice Address - Street 2:SUITE 204
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4853
Practice Address - Country:US
Practice Address - Phone:336-887-8400
Practice Address - Fax:336-887-3013
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEASTERN ORTHOPAEDIC SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1190220002OtherDME LOCATION PROVIDER NUM