=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902209877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2014
-----------------------------------------------------
Last Update Date | 10/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 N BOND ST
-----------------------------------------------------
City | ROWLAND
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28383-9741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-422-3350
-----------------------------------------------------
Fax | 910-422-3936
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2002 N CEDAR ST STE B
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28358-3926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-272-3048
-----------------------------------------------------
Fax | 910-738-3764
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. FORDHAM B. BRITT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-671-5026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | H0064
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | H0064
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------