Provider Demographics
NPI:1780241729
Name:SOUTHEAST REGIONAL MEDICAL SOLUTIONS, PLLC
Entity type:Organization
Organization Name:SOUTHEAST REGIONAL MEDICAL SOLUTIONS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOOKHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-229-8868
Mailing Address - Street 1:310 RIVER FOREST LN
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2506 LAKELAND DR STE 310
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7640
Practice Address - Country:US
Practice Address - Phone:769-487-6036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty