Provider Demographics
NPI:1356543383
Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:F
Authorized Official - Last Name:NICOSIA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:910-738-4554
Mailing Address - Street 1:1031 GATESVILLE DR
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-8001
Mailing Address - Country:US
Mailing Address - Phone:910-426-9346
Mailing Address - Fax:
Practice Address - Street 1:4895 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2162
Practice Address - Country:US
Practice Address - Phone:910-738-4554
Practice Address - Fax:910-739-4027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8799282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital