Basic Information
| Provider Information | |||||||||
| NPI: | 1427017169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST WOMEN'S CENTER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S 3RD ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199384040 | ||||||||
| FaxNumber: | 9199384075 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S 3RD ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199384040 | ||||||||
| FaxNumber: | 9199384075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 11/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | DUNCAN | ||||||||
| AuthorizedOfficialFirstName: | SHELLIE | ||||||||
| AuthorizedOfficialMiddleName: | SIMPKINS | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9199384040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 89015W1 | 05 | NC | MEDICAID |