Provider Demographics
NPI:1639536089
Name:SOUTHEASTERN SURGERY
Entity Type:Organization
Organization Name:SOUTHEASTERN SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DUFFY
Authorized Official - Last Name:DEWALT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:740-385-1881
Mailing Address - Street 1:12413 STATE ROUTE 93 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-9306
Mailing Address - Country:US
Mailing Address - Phone:740-385-3318
Mailing Address - Fax:740-385-1875
Practice Address - Street 1:144 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138
Practice Address - Country:US
Practice Address - Phone:740-385-1881
Practice Address - Fax:740-385-1875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34. 002686261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center