Provider Demographics
NPI:1922340520
Name:SOUTHEASTERN MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN MEDICAL GROUP, LLC
Other - Org Name:MADISON FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-722-0555
Mailing Address - Street 1:1230 SLAUGHTER RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-5900
Mailing Address - Country:US
Mailing Address - Phone:256-722-0555
Mailing Address - Fax:256-830-5135
Practice Address - Street 1:1230 SLAUGHTER RD
Practice Address - Street 2:SUITE C
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-5900
Practice Address - Country:US
Practice Address - Phone:256-722-0555
Practice Address - Fax:256-830-5135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty