Provider Demographics
NPI:1801979596
Name:SOUTHEASTERN MEDICAL BROKERS, INC.
Entity type:Organization
Organization Name:SOUTHEASTERN MEDICAL BROKERS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BYLER
Authorized Official - Suffix:
Authorized Official - Credentials:ATP, RTS
Authorized Official - Phone:706-855-8988
Mailing Address - Street 1:4490 WASHINGTON RD STE 16
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5898
Mailing Address - Country:US
Mailing Address - Phone:706-855-8988
Mailing Address - Fax:706-855-8902
Practice Address - Street 1:4490 WASHINGTON RD STE 16
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-5898
Practice Address - Country:US
Practice Address - Phone:706-855-8988
Practice Address - Fax:706-855-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA703994050BMedicaid
SCDE2463Medicaid
GA52036372001OtherBCBS
GA=========OtherTRICARE
GA52036372001OtherBCBS