Provider Demographics
NPI:1588720072
Name:SOUTHEASTERN GASTROENTEROLOGY ENDOSCOPY CENTER, PA
Entity type:Organization
Organization Name:SOUTHEASTERN GASTROENTEROLOGY ENDOSCOPY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANTHOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGUSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-739-0770
Mailing Address - Street 1:101 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3014
Mailing Address - Country:US
Mailing Address - Phone:910-739-0770
Mailing Address - Fax:910-739-4102
Practice Address - Street 1:101 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3014
Practice Address - Country:US
Practice Address - Phone:910-739-0770
Practice Address - Fax:910-739-4102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC138988261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409832Medicaid
NC02BBDOtherBCBS
NC2381198Medicare PIN