Healthcare Provider Details

I. General information

NPI: 1417191941
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S MAIN ST
RED SPRINGS NC
28377-1622
US

IV. Provider business mailing address

2600 N ELM ST
LUMBERTON NC
28358-3011
US

V. Phone/Fax

Practice location:
  • Phone: 910-865-5955
  • Fax: 910-738-3764
Mailing address:
  • Phone: 910-272-3051
  • Fax: 910-738-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberH0064
License Number StateNC

VIII. Authorized Official

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