Provider Demographics
NPI:1730192626
Name:SOUTHEASTERN MEDICAL, PA
Entity type:Organization
Organization Name:SOUTHEASTERN MEDICAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEPORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-575-5750
Mailing Address - Street 1:830 SUNSET BLVD N
Mailing Address - Street 2:
Mailing Address - City:SUNSET BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28468-4262
Mailing Address - Country:US
Mailing Address - Phone:910-575-5750
Mailing Address - Fax:910-575-5751
Practice Address - Street 1:830 SUNSET BLVD N
Practice Address - Street 2:
Practice Address - City:SUNSET BEACH
Practice Address - State:NC
Practice Address - Zip Code:28468-4262
Practice Address - Country:US
Practice Address - Phone:910-575-5750
Practice Address - Fax:910-575-5751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10022174400000X
NC96-01376208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911413Medicaid
NC11413OtherBLUE CROSS DR LEPORE
NC8911413Medicaid
NC11413OtherBLUE CROSS DR LEPORE
NCG39800Medicare UPIN
NC2233110AMedicare ID - Type UnspecifiedDR LEPORE