Provider Demographics
NPI:1598746059
Name:SOUTHEASTERN ENDOCRINE & DIABETES, P.C.
Entity Type:Organization
Organization Name:SOUTHEASTERN ENDOCRINE & DIABETES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROSENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:678-325-2250
Mailing Address - Street 1:1475 HOLCOMB BRIDGE RD
Mailing Address - Street 2:SUITE 129
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2139
Mailing Address - Country:US
Mailing Address - Phone:678-325-2250
Mailing Address - Fax:678-325-2261
Practice Address - Street 1:1475 HOLCOMB BRIDGE RD
Practice Address - Street 2:SUITE 129
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2139
Practice Address - Country:US
Practice Address - Phone:678-325-2250
Practice Address - Fax:678-325-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP5196Medicare ID - Type Unspecified