Provider Demographics
NPI:1396944633
Name:SOUTHEASTERN CARDIOLOGY
Entity type:Organization
Organization Name:SOUTHEASTERN CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:ELLIOTT-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:912-537-8988
Mailing Address - Street 1:1811 EDWINA DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8963
Mailing Address - Country:US
Mailing Address - Phone:912-537-8988
Mailing Address - Fax:912-608-8037
Practice Address - Street 1:1811 EDWINA DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8963
Practice Address - Country:US
Practice Address - Phone:912-537-8988
Practice Address - Fax:912-608-8037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53388207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E75547Medicare UPIN