Provider Demographics
NPI:1467536763
Name:SOUTHEAST PODIATRY PC
Entity type:Organization
Organization Name:SOUTHEAST PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:251-928-6768
Mailing Address - Street 1:23937 US HIGHWAY 98 STE 1
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532
Mailing Address - Country:US
Mailing Address - Phone:251-928-6768
Mailing Address - Fax:251-928-0783
Practice Address - Street 1:23937 US HWY 98 STE 1
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532
Practice Address - Country:US
Practice Address - Phone:251-928-6768
Practice Address - Fax:251-928-0783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDF2596Medicare PIN
AL1231320001Medicare NSC
ALK346Medicare PIN
FLK5915Medicare PIN