Provider Demographics
NPI:1902209877
Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Other - Org Name:SOUTHEASTERN MEDICAL CLINIC ROWLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FORDHAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5026
Mailing Address - Street 1:2002 N CEDAR ST STE B
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3926
Mailing Address - Country:US
Mailing Address - Phone:910-272-3048
Mailing Address - Fax:910-738-3764
Practice Address - Street 1:102 N BOND ST
Practice Address - Street 2:
Practice Address - City:ROWLAND
Practice Address - State:NC
Practice Address - Zip Code:28383-9741
Practice Address - Country:US
Practice Address - Phone:910-422-3350
Practice Address - Fax:910-422-3936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0064207Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty