Provider Demographics
NPI:1467568907
Name:SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Entity Type:Organization
Organization Name:SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:OSTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-535-8691
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-535-3011
Mailing Address - Fax:912-538-5529
Practice Address - Street 1:ONE MEADOWS PARKWAY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8921
Practice Address - Country:US
Practice Address - Phone:912-535-3011
Practice Address - Fax:912-537-5366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
261QM1300X, 261QP2300X, 261QR0200X, 261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6364Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER