Provider Demographics
NPI:1013335009
Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Other - Org Name:WOUND CARE PROFESSIONAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
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 1:2600 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3011
Mailing Address - Country:US
Mailing Address - Phone:910-272-3051
Mailing Address - Fax:910-738-3764
Practice Address - Street 1:103 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3014
Practice Address - Country:US
Practice Address - Phone:910-738-3836
Practice Address - Fax:910-738-3959
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEASTERN REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0064302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization