Healthcare Provider Details

I. General information

NPI: 1629012935
Provider Name (Legal Business Name): SOUTHEASTERN ORTHOPAEDIC SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 N CHURCH ST SUITE 100
GREENSBORO NC
27401-1008
US

IV. Provider business mailing address

1130 N CHURCH ST SUITE 100
GREENSBORO NC
27401-1008
US

V. Phone/Fax

Practice location:
  • Phone: 336-375-2300
  • Fax: 336-375-2314
Mailing address:
  • Phone: 336-375-2300
  • Fax: 336-375-2314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROBERT A WAINER
Title or Position: SENIOR PARTNER
Credential: MD
Phone: 336-375-2300