Healthcare Provider Details

I. General information

NPI: 1336797349
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 DAWN DR STE 1200
LUMBERTON NC
28360-0004
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 910-671-4214
  • Fax: 910-671-4215
Mailing address:
  • Phone: 910-272-3048
  • Fax: 910-738-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: ELLA HUNT
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 910-737-3147