Healthcare Provider Details

I. General information

NPI: 1831687912
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 OAKRIDGE BLVD
LUMBERTON NC
28358-2330
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 910-738-2454
  • Fax: 910-671-9303
Mailing address:
  • Phone: 910-272-3048
  • Fax: 910-671-5538

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: CHARLES THOMAS JOHNSON
Title or Position: VP/CFO
Credential:
Phone: 910-671-5090