Provider Demographics
NPI:1811900178
Name:SOUTHEASTERN MEDICAL CENTER, P.C.
Entity type:Organization
Organization Name:SOUTHEASTERN MEDICAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:RMM
Authorized Official - Phone:910-892-4941
Mailing Address - Street 1:700 TILGHMAN DR
Mailing Address - Street 2:SUITE720
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-0007
Mailing Address - Country:US
Mailing Address - Phone:910-892-4941
Mailing Address - Fax:
Practice Address - Street 1:700 TILGHMAN DR
Practice Address - Street 2:SUITE720
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-0007
Practice Address - Country:US
Practice Address - Phone:910-892-4941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401258174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2203474Medicare ID - Type Unspecified