Healthcare Provider Details

I. General information

NPI: 1215289038
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W 27TH ST
LUMBERTON NC
28358-3016
US

IV. Provider business mailing address

300 W 27TH ST
LUMBERTON NC
28358-3075
US

V. Phone/Fax

Practice location:
  • Phone: 910-738-8222
  • Fax: 910-671-0846
Mailing address:
  • Phone: 910-738-8222
  • Fax: 910-671-8512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES T. JOHNSON III
Title or Position: DIRECTOR
Credential:
Phone: 910-671-5090