Provider Demographics
NPI:1912288135
Name:SOUTHEAST ENT & FACIAL PLASTIC SURGEYR, PC
Entity Type:Organization
Organization Name:SOUTHEAST ENT & FACIAL PLASTIC SURGEYR, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-330-5030
Mailing Address - Street 1:1000 TOWNE CENTER BLVD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4052
Mailing Address - Country:US
Mailing Address - Phone:912-330-5030
Mailing Address - Fax:912-330-5033
Practice Address - Street 1:1000 TOWNE CENTER BLVD
Practice Address - Street 2:SUITE 501
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4052
Practice Address - Country:US
Practice Address - Phone:912-330-5030
Practice Address - Fax:912-330-5033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035071207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty