Basic Information
| Provider Information | |||||||||
| NPI: | 1356379382 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEASTERN EMERGENCY PHYSICIANS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SEP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452634706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882031274 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1924 ALCOA HWY | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655449000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CORVINI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3478841707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 2080P0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 291U00000X | WV | N | Laboratories | Clinical Medical Laboratory | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3728386 | 05 | TN | MEDICAID | 5902177 | 05 | NC | MEDICAID | GP3694 | 05 | SC | MEDICAID | 157777002 | 05 | AR | MEDICAID | 529931890 | 05 | AL | MEDICAID | 001740238 | 01 | WV | MOUNTAIN STATES BLUE CROSS | OTHER | 017E9 | 01 | NC | BCBS OF NC | OTHER | 156473002 | 05 | AR | MEDICAID | 5901815 | 05 | NC | MEDICAID | GP3965 | 05 | SC | MEDICAID | 507198802 | 05 | MO | MEDICAID | 5C346 | 01 | AR | BS AR | OTHER | 4005131000 | 05 | WV | MEDICAID | 65937690 | 05 | KY | MEDICAID | 65934218 | 05 | KY | MEDICAID |