MEDICARE: SOUTHEASTERN REGIONAL MEDICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	H0064	NC

General Provider Information

NPI Number	:	1326275728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN REGIONAL MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	2600 N ELM ST
Second Line	:
City	:	LUMBERTON
State	:	NC
Zip	:	28358-3011
Country	:	US
Telephone Number	:	910-272-3051
Fax Number	:	910-738-3764

Provider Business Practice Location Address
First Line	:	15 W.3RD ST.
Second Line	:
City	:	PARKTON
State	:	NC
Zip	:	28371-0128
Country	:	US
Telephone Number	:	910-858-3913
Fax Number	:	910-738-3764

Authorized Official
Title or Position	:	CFO
Name	:	CHARLES T. JOHNSON III
Credential	:
Telephone Number	:	910-671-5090

Provider Enumeration Date	:	06/12/2009
Last Update Date	:	06/23/2009

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