Healthcare Provider Details

I. General information

NPI: 1780241729
Provider Name (Legal Business Name): SOUTHEAST REGIONAL MEDICAL SOLUTIONS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 LAKELAND DR STE 310
FLOWOOD MS
39232-7640
US

IV. Provider business mailing address

310 RIVER FOREST LN
BRANDON MS
39047-7020
US

V. Phone/Fax

Practice location:
  • Phone: 769-487-6036
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHEAL L BOOKHARDT
Title or Position: OWNER
Credential: MD
Phone: 321-229-8868