Provider Demographics
NPI:1467006197
Name:SOUTHEASTERN MEDICAL, PA
Entity Type:Organization
Organization Name:SOUTHEASTERN MEDICAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-287-7001
Mailing Address - Street 1:830 SUNSET BLVD N
Mailing Address - Street 2:
Mailing Address - City:SUNSET BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28468-4262
Mailing Address - Country:US
Mailing Address - Phone:910-575-5750
Mailing Address - Fax:
Practice Address - Street 1:830 SUNSET BLVD N
Practice Address - Street 2:
Practice Address - City:SUNSET BEACH
Practice Address - State:NC
Practice Address - Zip Code:28468-4262
Practice Address - Country:US
Practice Address - Phone:910-575-5750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911413Medicaid