Healthcare Provider Details

I. General information

NPI: 1437652815
Provider Name (Legal Business Name): SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 MEADOWS LN STE H
VIDALIA GA
30474-7201
US

IV. Provider business mailing address

PO BOX 407
VIDALIA GA
30475-0407
US

V. Phone/Fax

Practice location:
  • Phone: 912-538-0040
  • Fax:
Mailing address:
  • Phone: 912-538-0040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: TONY M O'STEEN
Title or Position: CFO
Credential:
Phone: 912-535-5560