Provider Demographics
NPI:1467406041
Name:SOUTHEASTERN ORTHOPAEDICS
Entity Type:Organization
Organization Name:SOUTHEASTERN ORTHOPAEDICS
Other - Org Name:SOUTHEASTERN HAND AND OCCUPATIONAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MCMAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-866-8976
Mailing Address - Street 1:760 N NEW HOPE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054
Mailing Address - Country:US
Mailing Address - Phone:704-866-8976
Mailing Address - Fax:704-866-8680
Practice Address - Street 1:760 N NEW HOPE RD
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-866-8976
Practice Address - Fax:704-866-8680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC320225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC014C3OtherBCBS INDIVIDUAL
NC2510738Medicare ID - Type UnspecifiedGRP
NC014C3OtherBCBS INDIVIDUAL