Healthcare Provider Details

I. General information

NPI: 1376065854
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2936 N ELM ST STE 102
LUMBERTON NC
28358-2981
US

IV. Provider business mailing address

PO BOX 749193
ATLANTA GA
30374-9193
US

V. Phone/Fax

Practice location:
  • Phone: 910-671-6619
  • Fax: 910-608-0487
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 StateNC

VIII. Authorized Official

Name: SARA BETH BRADLEY
Title or Position: VP/CFO
Credential:
Phone: 910-671-5297