Healthcare Provider Details

I. General information

NPI: 1336353093
Provider Name (Legal Business Name): SOUTHEASTERN NEUROLOGY ASSOCIATES,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5211 HIGHWAY 278 NE
COVINGTON GA
30014-2671
US

IV. Provider business mailing address

5211 HIGHWAY 278 NE
COVINGTON GA
30014-2671
US

V. Phone/Fax

Practice location:
  • Phone: 770-787-8210
  • Fax: 770-787-8228
Mailing address:
  • Phone: 770-787-8210
  • Fax: 770-787-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number043773
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number56605
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN120924-NP
License Number StateGA

VIII. Authorized Official

Name: MRS. CLAUDIA J WEAVER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-787-8200