NPIViewer - Provider NPI 1427282045

NPI:	1427282045
Name:	SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity type:	Organization
Organization Name:	SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:	CFO
Authorized Official - Prefix:
Authorized Official - First Name:	CHARLES
Authorized Official - Middle Name:	T
Authorized Official - Last Name:	JOHNSON
Authorized Official - Suffix:	III
Authorized Official - Credentials:
Authorized Official - Phone:	910-671-5090
Mailing Address - Street 1:	2002 N CEDAR ST STE B
Mailing Address - Street 2:
Mailing Address - City:	LUMBERTON
Mailing Address - State:	NC
Mailing Address - Zip Code:	28358-3926
Mailing Address - Country:	US
Mailing Address - Phone:	910-272-3048
Mailing Address - Fax:	910-738-3764
Practice Address - Street 1:	2002 N CEDAR ST STE B
Practice Address - Street 2:
Practice Address - City:	LUMBERTON
Practice Address - State:	NC
Practice Address - Zip Code:	28358-3926
Practice Address - Country:	US
Practice Address - Phone:	910-272-3048
Practice Address - Fax:	910-738-3764
EIN:	<UNAVAIL>
Is Organization Subpart?:	No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:	2009-05-11
Last Update Date:	2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:

State	License ID	Taxonomies
NC	H0064	261QM1300X, 261QR1300X

Primary?	Code	Type	Classification	Specialization
Yes	261QM1300X	Ambulatory Health Care Facilities	Clinic/Center	Multi-Specialty
No	261QR1300X	Ambulatory Health Care Facilities	Clinic/Center	Rural Health

State	Identifier ID	ID Type	Issuer
NC	022WP	Other	BCBS
NC	022WT	Other	BCBS
NC	023R1	Other	BCBS
NC	344638C	Medicaid
NC	344641A	Medicaid
NC	5917766	Medicaid
NC	344639A	Medicaid
NC	344642A	Medicaid
NC	5914045	Medicaid
NC	5921524	Medicaid
NC	348954A	Medicaid
NC	348954C	Medicaid
NC	348961C	Medicaid
NC	5914044	Medicaid
NC	5917135	Medicaid
NC	5918279	Medicaid
NC	344639C	Medicaid
NC	344642C	Medicaid
NC	5914043	Medicaid
NC	5914048	Medicaid
NC	5914049	Medicaid
NC	5914051	Medicaid
NC	022WN	Other	BCBS
NC	344647C	Medicaid
NC	5917396	Medicaid
NC	022WR	Other	BCBS
NC	022WU	Other	BCBS
NC	025F5	Other	BCBS
NC	344647A	Medicaid
NC	348961A	Medicaid
NC	5914168	Medicaid
NC	5916164	Medicaid
NC	344641C	Medicaid
NC	5913422	Medicaid
NC	5914047	Medicaid
NC	5917954	Medicaid
NC	022WG	Other	BCBS
NC	344638A	Medicaid
NC	5914050	Medicaid
NC	5914429	Medicaid
NC	344641C	Medicaid
NC	5921524	Medicaid
NC	344647C	Medicaid
NC	5914429	Medicaid
NC	348964	Medicare PIN
NC	34-8962	Medicare PIN
NC	022WR	Other	BCBS
NC	344642A	Medicaid
NC	5914168	Medicaid
NC	34-8961	Medicare PIN