Provider Demographics
NPI:1922193705
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:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-273-7900
Mailing Address - Street 1:1816 RICHARDSON DR
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5434
Mailing Address - Country:US
Mailing Address - Phone:336-342-4446
Mailing Address - Fax:336-342-7747
Practice Address - Street 1:1816 RICHARDSON DR
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5434
Practice Address - Country:US
Practice Address - Phone:336-342-4446
Practice Address - Fax:336-342-7747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0129FOtherBCBS NC
NC790129FMedicaid
NC790129FMedicaid