Provider Demographics
NPI:1487632873
Name:SOUTHEASTERN SPECIALIST CLINIC
Entity Type:Organization
Organization Name:SOUTHEASTERN SPECIALIST CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:704-867-8975
Mailing Address - Street 1:825 MAJESTIC COURT
Mailing Address - Street 2:SUITE F
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054
Mailing Address - Country:US
Mailing Address - Phone:704-867-8975
Mailing Address - Fax:704-867-8353
Practice Address - Street 1:825 MAJESTIC CT
Practice Address - Street 2:SUITE F
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5186
Practice Address - Country:US
Practice Address - Phone:704-867-8975
Practice Address - Fax:704-867-8353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19633174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8958807Medicaid
NCC81006Medicare UPIN
NC8958807Medicaid