MEDICARE: SOUTHEASTERN MEDICAL SUPPLY INC

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	332B00000X	Durable Medical Equipment & Medical Supplies	1386679009	SC

General Provider Information

NPI Number	:	1386679009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	1024 WILDWOOD CENTRE DR
Second Line	:	SUITE A
City	:	COLUMBIA
State	:	SC
Zip	:	29229-8400
Country	:	US
Telephone Number	:	803-233-3691
Fax Number	:	803-233-6140

Provider Business Practice Location Address
First Line	:	1024 WILDWOOD CENTRE DR
Second Line	:	SUITE A
City	:	COLUMBIA
State	:	SC
Zip	:	29229-8400
Country	:	US
Telephone Number	:	803-233-3691
Fax Number	:	803-233-6140

Authorized Official
Title or Position	:	SECRETARY/INSURANCE COORDINATOR
Name	:	MR. MARY E NODELMAN
Credential	:
Telephone Number	:	803-233-3691

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	11/20/2008

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