Provider Demographics
NPI:1093389231
Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity type:Organization
Organization Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CRO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5083
Mailing Address - Street 1:PO BOX 749193
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9193
Mailing Address - Country:US
Mailing Address - Phone:984-974-4372
Mailing Address - Fax:
Practice Address - Street 1:1249 CHICKEN FOOT RD STE C
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-7525
Practice Address - Country:US
Practice Address - Phone:910-779-1967
Practice Address - Fax:910-779-1968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-13
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center