Provider Demographics
NPI:1508921818
Name:SOUTHEAST GYNECOLOGICAL SPECIALTY PA
Entity Type:Organization
Organization Name:SOUTHEAST GYNECOLOGICAL SPECIALTY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MCC
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-974-5190
Mailing Address - Street 1:2964 N STATE ROAD 7
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5755
Mailing Address - Country:US
Mailing Address - Phone:954-974-5190
Mailing Address - Fax:954-974-0743
Practice Address - Street 1:2964 N STATE ROAD 7
Practice Address - Street 2:SUITE 100
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5755
Practice Address - Country:US
Practice Address - Phone:954-974-5190
Practice Address - Fax:954-974-0743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5625Medicare PIN