Basic Information
| Provider Information | |||||||||
| NPI: | 1083117469 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEAST REGIONAL PRIMARY CARE CORPORATION | ||||||||
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| OtherOrganizationName: | MEADOWS MEDICAL GROUP ENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 407 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304750407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125373384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1707 MEADOWS LN STE C | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304747201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125373384 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2018 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | O'STEEN | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9125355560 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YS0123X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | 207Y00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.