MEDICARE: SOUTHEASTERN REGIONAL MEDICAL CENTER

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	261QM2500X	Medical Specialty Clinic/Center	H0064	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	016C0	OTHER	NC	BCBSNC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376507715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN REGIONAL MEDICAL CENTER

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	:	106 FARM BROOK DR
Second Line	:	SUITE A
City	:	LUMBERTON
State	:	NC
Zip	:	28358-2178
Country	:	US
Telephone Number	:	910-671-8556
Fax Number	:	910-671-9299

Authorized Official
Title or Position	:	VICE PRESIDENT FINANCE
Name	:	MR. C. THOMAS JOHNSON III
Credential	:	CFO
Telephone Number	:	910-671-5090

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	11/04/2009

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Directions to “SOUTHEASTERN REGIONAL MEDICAL CENTER ” Practice Location

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