Healthcare Provider Details

I. General information

NPI: 1093389231
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1249 CHICKEN FOOT RD STE C
HOPE MILLS NC
28348-7525
US

IV. Provider business mailing address

PO BOX 749193
ATLANTA GA
30374-9193
US

V. Phone/Fax

Practice location:
  • Phone: 910-779-1967
  • Fax: 910-779-1968
Mailing address:
  • Phone: 984-974-4372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHARLES THOMAS JOHNSON
Title or Position: CRO
Credential:
Phone: 910-671-5083