Provider Demographics
NPI:1275648420
Name:SOUTHEASTERN WOUND CARE
Entity Type:Organization
Organization Name:SOUTHEASTERN WOUND CARE
Other - Org Name:PAIN AND WOUND CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ODEANE
Authorized Official - Middle Name:H
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-546-9558
Mailing Address - Street 1:705 SOUTH 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901
Mailing Address - Country:US
Mailing Address - Phone:256-546-9558
Mailing Address - Fax:
Practice Address - Street 1:705 SOUTH 3RD STREET
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901
Practice Address - Country:US
Practice Address - Phone:256-546-9558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00023743174400000X
AL1089350363L00000X
AL1082016363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPENDINGMedicare UPIN
ALJ826Medicare ID - Type UnspecifiedOFFICE IDENTIFICATION NUM
ALG21753Medicare UPIN
ALQ48386Medicare UPIN