Provider Demographics
NPI:1629469895
Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity type:Organization
Organization Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5297
Mailing Address - Street 1:PO BOX 749193
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9193
Mailing Address - Country:US
Mailing Address - Phone:984-974-4372
Mailing Address - Fax:
Practice Address - Street 1:730 OAKRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2324
Practice Address - Country:US
Practice Address - Phone:910-738-2662
Practice Address - Fax:910-738-3730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty