Provider Demographics
NPI:1760410385
Name:HOSPITAL PHYSICIAN SERVICES - SOUTHEAST PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:HOSPITAL PHYSICIAN SERVICES - SOUTHEAST PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SCANLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-377-2954
Mailing Address - Street 1:1643 NW 136TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2857
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:2151 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-3202
Practice Address - Country:US
Practice Address - Phone:770-267-8461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA638161388AMedicaid
GADE6935OtherMEDICARE TRAVELERS RR
GADE6935OtherMEDICARE TRAVELERS RR