Provider Demographics
NPI:1689772220
Name:SOUTHEASTERN HEART & VASCULAR CENTER PA
Entity Type:Organization
Organization Name:SOUTHEASTERN HEART & VASCULAR CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-273-7900
Mailing Address - Street 1:3200 NORTHLINE AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7616
Mailing Address - Country:US
Mailing Address - Phone:336-273-7900
Mailing Address - Fax:336-273-8147
Practice Address - Street 1:3200 NORTHLINE AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7619
Practice Address - Country:US
Practice Address - Phone:336-273-7900
Practice Address - Fax:336-273-8147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790129FMedicaid
NC0129FOtherBCBS NC
NC2325574Medicare ID - Type Unspecified