Provider Demographics
NPI:1609986082
Name:SOUTHEAST REHAB MEDICINE INC
Entity Type:Organization
Organization Name:SOUTHEAST REHAB MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:205-685-8040
Mailing Address - Street 1:PO BOX 1223
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:AL
Mailing Address - Zip Code:35040-1223
Mailing Address - Country:US
Mailing Address - Phone:205-685-8040
Mailing Address - Fax:205-685-8077
Practice Address - Street 1:3800 RIDGEWAY DR
Practice Address - Street 2:MAGNOLIA HALL
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-5506
Practice Address - Country:US
Practice Address - Phone:205-868-2096
Practice Address - Fax:205-868-2097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherTAX ID
ALD312Medicare ID - Type Unspecified