Provider Demographics
NPI:1356774855
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:MICHAEL
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5044
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 1:2934 N ELM ST
Practice Address - Street 2:SUITE B
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2986
Practice Address - Country:US
Practice Address - Phone:910-272-1175
Practice Address - Fax:910-272-1174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0064261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care