Provider Demographics
| NPI: | 1356379382 |
|---|---|
| Name: | SOUTHEASTERN EMERGENCY PHYSICIANS LLC |
| Entity type: | Organization |
| Organization Name: | SOUTHEASTERN EMERGENCY PHYSICIANS LLC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | MICHAEL |
| Authorized Official - Middle Name: | D |
| Authorized Official - Last Name: | CORVINI |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 347-884-1707 |
| Mailing Address - Street 1: | 265 BROOKVIEW CENTRE WAY STE 203 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | KNOXVILLE |
| Mailing Address - State: | TN |
| Mailing Address - Zip Code: | 37919-4053 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 888-203-1274 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 989 MEDICAL PARK DR |
| Practice Address - Street 2: | |
| Practice Address - City: | MAYSVILLE |
| Practice Address - State: | KY |
| Practice Address - Zip Code: | 41056-8750 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 606-759-5311 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-06-29 |
| Last Update Date: | 2024-02-08 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207PP0204X, 2080P0204X, 208M00000X, 363A00000X, 363AM0700X, 363L00000X, 363LP0200X, 207P00000X | ||
| WV | 291U00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207PP0204X | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | Group - Multi-Specialty |
| No | 2080P0204X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | Group - Multi-Specialty |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 291U00000X | Laboratories | Clinical Medical Laboratory | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| WV | 001740238 | Other | MOUNTAIN STATES BLUE CROSS |
| AR | 5C346 | Other | BS AR |
| TN | 3728386 | Medicaid | |
| MO | 507198802 | Medicaid | |
| NC | 5901815 | Medicaid | |
| SC | GP3694 | Medicaid | |
| AR | 157777002 | Medicaid | |
| KY | 65934218 | Medicaid | |
| WV | 4005131000 | Medicaid | |
| AL | 529931890 | Medicaid | |
| SC | GP3965 | Medicaid | |
| AR | 156473002 | Medicaid | |
| NC | 5902177 | Medicaid | |
| KY | 65937690 | Medicaid | |
| NC | 017E9 | Other | BCBS OF NC |
| SC | DC8081 | Medicare PIN | |
| NC | 2345989 | Medicare PIN | |
| MS | C03276 | Medicare PIN | |
| TN | 3278386 | Medicare PIN | |
| MS | DC7496 | Medicare PIN | |
| VA | C09546 | Medicare PIN | |
| AR | 157777002 | Medicaid | |
| TN | 3728386 | Medicaid | |
| AR | 5C346 | Medicare PIN | |
| SC | GP3694 | Medicaid | |
| WV | DD7401 | Medicare PIN | |
| KY | 9543 | Medicare PIN | |
| WV | 4005131000 | Medicaid | |
| TN | CC0920 | Medicare PIN |
