Provider Demographics
NPI:1518066984
Name:SOUTHEAST FAMILY HEALTHCARE PC
Entity Type:Organization
Organization Name:SOUTHEAST FAMILY HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LASSITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-983-5994
Mailing Address - Street 1:15079 S US HIGHWAY 231
Mailing Address - Street 2:
Mailing Address - City:MIDLAND CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36350-6305
Mailing Address - Country:US
Mailing Address - Phone:334-983-5994
Mailing Address - Fax:334-983-4954
Practice Address - Street 1:15079 S US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:MIDLAND CITY
Practice Address - State:AL
Practice Address - Zip Code:36350-6305
Practice Address - Country:US
Practice Address - Phone:334-983-5994
Practice Address - Fax:334-983-4954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009996800Medicaid
AL009996800Medicaid
AL051509816Medicare PIN