Provider Demographics
NPI:1518215219
Name:SOUTHEASTERN SPINE, PLLC
Entity Type:Organization
Organization Name:SOUTHEASTERN SPINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:BESH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-505-4059
Mailing Address - Street 1:281 NORTH LYERLY STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-2728
Mailing Address - Country:US
Mailing Address - Phone:423-693-2175
Mailing Address - Fax:888-959-1015
Practice Address - Street 1:281 NORTH LYERLY STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-2728
Practice Address - Country:US
Practice Address - Phone:423-693-2175
Practice Address - Fax:888-959-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
103G701752Medicare PIN