SOUTHEASTERN EMERGENCY SERVICES P C

Provider Demographics

• NPI: 1669414264
• Name: SOUTHEASTERN EMERGENCY SERVICES P C
• Entity type: Organization
• Organization Name: SOUTHEASTERN EMERGENCY SERVICES P C
• Authorized Official - Title/Position: PRESIDENT
• Authorized Official - Prefix: DR
• Authorized Official - First Name: RANDAL
• Authorized Official - Middle Name: L
• Authorized Official - Last Name: DABBS
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 865-693-1000
• Mailing Address - Street 1: P O BOX 634760
• Mailing Address - City: CINCINNATI
• Mailing Address - State: OH
• Mailing Address - Zip Code: 45263-4760
• Mailing Address - Country: US
• Practice Address - Street 1: 1114 W MADISON AVE
• Practice Address - City: ATHENS
• Practice Address - State: TN
• Practice Address - Zip Code: 37371
• Practice Address - Country: US
• Practice Address - Phone: 423-745-1411
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-11
• Last Update Date: 2020-09-14

Provider Licenses

State	License ID	Taxonomies
		207PP0204X, 363A00000X, 363AM0700X, 363L00000X
TN		363L00000X, 363LP0200X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Single Specialty
No	207PP0204X	Allopathic & Osteopathic Physicians	Emergency Medicine	Pediatric Emergency Medicine	Group - Single Specialty
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Single Specialty
No	363AM0700X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Medical	Group - Single Specialty
No	363LP0200X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Pediatrics	Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NC	2348298	Medicaid
MS	05515899	Medicaid
MO	507432003	Medicaid
SC	GP4818	Medicaid
MS	02121280	Medicaid
AL	529929400	Medicaid
KY	78903671	Medicaid
MS	06310389	Medicaid
KY	7100010470	Medicaid
VA	C09682	Medicare PIN
KY	78903671	Medicaid
MS	06310389	Medicaid
MS	05515899	Medicaid
AL	529929400	Medicaid
NC	DE4026	Medicare PIN
MS	DC0840	Medicare PIN
WV	S09357841	Medicare PIN
AR	5F703	Medicare PIN
TN	CH3618	Medicare PIN
VA	DE7926	Medicare PIN
KY	DD5321	Medicare PIN
MS	02121280	Medicaid
NC	2348298	Medicaid
KY	6477	Medicare PIN
SC	CK8109	Medicare PIN