Provider Demographics
NPI:1710175500
Name:SOUTHEASTERN WOUND CARE SERVICES, INC
Entity Type:Organization
Organization Name:SOUTHEASTERN WOUND CARE SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SID
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-444-1293
Mailing Address - Street 1:1805 GALILEE CT
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7405
Mailing Address - Country:US
Mailing Address - Phone:404-444-1293
Mailing Address - Fax:404-601-6880
Practice Address - Street 1:1412 MILSTEAD AVE NE
Practice Address - Street 2:ROCKDALE MEDICAL CENTER
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3877
Practice Address - Country:US
Practice Address - Phone:678-413-7738
Practice Address - Fax:678-413-7739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59757207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty