Basic Information
| Provider Information | |||||||||
| NPI: | 1285687731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN ORTHOPAEDIC SPECIALISTS,PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 N CHURCH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363752300 | ||||||||
| FaxNumber: | 3363752314 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 N CHURCH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363752300 | ||||||||
| FaxNumber: | 3363752318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | WAINER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3363752300 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEASTERN ORTHOPAEDIC SPECIALISTS,PA | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 890206K | 05 | NC | MEDICAID |