=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982940987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEASTERN CARDIOVASCULAR ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2012
-----------------------------------------------------
Last Update Date | 12/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1076 BERMUDA RUN
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-0858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-871-7810
-----------------------------------------------------
Fax | 912-871-7820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1076 BERMUDA RUN
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-0858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-871-7810
-----------------------------------------------------
Fax | 912-871-7820
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANTHONY B CHAPPELL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 912-871-7810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------