Healthcare Provider Details

I. General information

NPI: 1376507715
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 FARM BROOK DR SUITE A
LUMBERTON NC
28358-2178
US

IV. Provider business mailing address

2600 N ELM ST
LUMBERTON NC
28358-3011
US

V. Phone/Fax

Practice location:
  • Phone: 910-671-8556
  • Fax: 910-671-9299
Mailing address:
  • Phone: 910-272-3051
  • Fax: 910-738-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberH0064
License Number StateNC

VIII. Authorized Official

Name: MR. C. THOMAS JOHNSON III
Title or Position: VICE PRESIDENT FINANCE
Credential: CFO
Phone: 910-671-5090