Healthcare Provider Details

I. General information

NPI: 1548672504
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 DAWN DR STE 2100
LUMBERTON NC
28360-0005
US

IV. Provider business mailing address

2002 N CEDAR ST STE B
LUMBERTON NC
28358-3926
US

V. Phone/Fax

Practice location:
  • Phone: 910-671-8556
  • Fax: 910-671-4850
Mailing address:
  • Phone: 910-272-3048
  • Fax: 910-738-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberH0064
License Number StateNC

VIII. Authorized Official

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