Provider Demographics
NPI:1922431535
Name:SOUTHEASTERN ORTHOPAEDIC SPECIALISTS, PA
Entity Type:Organization
Organization Name:SOUTHEASTERN ORTHOPAEDIC SPECIALISTS, PA
Other - Org Name:SPORTS MEDICINE & JOINT REPLACEMENT OF GREENSBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LUCEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-333-6443
Mailing Address - Street 1:201 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1205
Mailing Address - Country:US
Mailing Address - Phone:336-333-6443
Mailing Address - Fax:336-333-6441
Practice Address - Street 1:148 POINTE SOUTH DR
Practice Address - Street 2:
Practice Address - City:RANDLEMAN
Practice Address - State:NC
Practice Address - Zip Code:27317-9520
Practice Address - Country:US
Practice Address - Phone:336-799-4433
Practice Address - Fax:336-333-6441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBL 6497209207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty