Provider Demographics
NPI:1336234095
Name:SOUTHEASTERN SPORTS MEDICINE PLLC
Entity type:Organization
Organization Name:SOUTHEASTERN SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CARRAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-274-4555
Mailing Address - Street 1:23 TURTLE CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803
Mailing Address - Country:US
Mailing Address - Phone:828-274-4555
Mailing Address - Fax:828-274-3615
Practice Address - Street 1:23 TURTLE CREEK DR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-3152
Practice Address - Country:US
Practice Address - Phone:828-274-4555
Practice Address - Fax:828-274-3615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011FYOtherBCBS GROUP NUMBER
NC89011FYMedicaid
NC2344506Medicare ID - Type UnspecifiedPROVIDER NUMBER