Provider Demographics
NPI:1659508653
Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Other - Org Name:FAIRMONT MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5090
Mailing Address - Street 1:2600 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3011
Mailing Address - Country:US
Mailing Address - Phone:910-272-3051
Mailing Address - Fax:910-738-3764
Practice Address - Street 1:101 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1951
Practice Address - Country:US
Practice Address - Phone:910-628-0655
Practice Address - Fax:910-738-3764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0064261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health