Provider Demographics
NPI:1063779114
Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5090
Mailing Address - Street 1:PO BOX 890860
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0860
Mailing Address - Country:US
Mailing Address - Phone:910-671-5290
Mailing Address - Fax:910-671-8512
Practice Address - Street 1:2934 N. EL M ST.
Practice Address - Street 2:SUITE B
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2981
Practice Address - Country:US
Practice Address - Phone:910-272-1175
Practice Address - Fax:910-272-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0064261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care