MEDICARE: SOUTHEAST, 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	261QF0400X	Federally Qualified Health Center (FQHC)	0300	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609284470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST, INC.

Provider Business Mailing Address
First Line	:	16 W LONG ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43215-2815
Country	:	US
Telephone Number	:	614-225-0990
Fax Number	:	614-225-0991

Provider Business Practice Location Address
First Line	:	595 VAN BUREN DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43223-2230
Country	:	US
Telephone Number	:	614-225-0980
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. CHARLES TONG
Credential	:
Telephone Number	:	614-813-0177

Provider Enumeration Date	:	07/24/2014
Last Update Date	:	01/16/2026

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