Healthcare Provider Details

I. General information

NPI: 1144388174
Provider Name (Legal Business Name): SOUTHEASTERN SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 JOHNSON FERRY ROAD SUITE 200
ATLANTA GA
30342
US

IV. Provider business mailing address

1100 JOHNSON FERRY ROAD SUITE 200
ATLANTA GA
30342
US

V. Phone/Fax

Practice location:
  • Phone: 404-257-1900
  • Fax: 404-257-0792
Mailing address:
  • Phone: 404-257-1900
  • Fax: 404-257-0792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. H RON H DAVIDSON
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 404-459-3473