Healthcare Provider Details

I. General information

NPI: 1184669053
Provider Name (Legal Business Name): SOUTHEASTERN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 HOSPITAL DR
BREVARD NC
28712-3378
US

IV. Provider business mailing address

PO BOX 636020
CINCINNATI OH
45263-6020
US

V. Phone/Fax

Practice location:
  • Phone: 828-884-9111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDAL L DABBS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 865-693-1000