Provider Demographics
NPI:1356767669
Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity type:Organization
Organization Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:22401 ANDREW JACKSON HWY
Practice Address - Street 2:
Practice Address - City:MAXTON
Practice Address - State:NC
Practice Address - Zip Code:28364-6721
Practice Address - Country:US
Practice Address - Phone:910-844-2004
Practice Address - Fax:910-844-3798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0064207Q00000X, 261QP2300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care