Healthcare Provider Details

I. General information

NPI: 1477535508
Provider Name (Legal Business Name): SOUTHEAST PERINATAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 SW 84TH AVE SUITE 104
PLANTATION FL
33324-2754
US

IV. Provider business mailing address

5565 CENTERVIEW DR STE 107
RALEIGH NC
27606-3563
US

V. Phone/Fax

Practice location:
  • Phone: 954-476-6229
  • Fax: 954-476-4679
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN KONDAS
Title or Position: OFFICER
Credential:
Phone: 877-328-1119