Provider Demographics
NPI:1528264629
Name:SOUTHEASTERN CARDIOVASCULAR IMG, INC.
Entity type:Organization
Organization Name:SOUTHEASTERN CARDIOVASCULAR IMG, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:PAINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-537-9826
Mailing Address - Street 1:1006A MOUNT VERNON RD
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-3029
Mailing Address - Country:US
Mailing Address - Phone:912-537-9826
Mailing Address - Fax:912-537-2182
Practice Address - Street 1:1006A MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-3029
Practice Address - Country:US
Practice Address - Phone:912-537-9826
Practice Address - Fax:912-537-2182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028618207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000327346DMedicaid
GAGRP2455Medicare PIN
GAD30411Medicare UPIN