Provider Demographics
NPI:1982037578
Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Other - Org Name:SOUTHEASTERN PALLIATIVE CARE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5090
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:910-671-5600
Mailing Address - Fax:910-739-3551
Practice Address - Street 1:2002 N CEDAR ST STE B
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3926
Practice Address - Country:US
Practice Address - Phone:910-671-5600
Practice Address - Fax:910-739-3551
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEASTERN REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHOS1599363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty