Basic Information
| Provider Information | |||||||||
| NPI: | 1598090839 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST PHYSICIAN NETWORK, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 AFFLINK PL STE 101 | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354062452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053458208 | ||||||||
| FaxNumber: | 2053458209 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410 MCFARLAND BLVD N | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354062209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053458208 | ||||||||
| FaxNumber: | 2053458209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2009 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | SANFORD | ||||||||
| AuthorizedOfficialFirstName: | SHELBY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2053458208 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 10900 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 208800000X | 10900 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207RH0003X | 10900 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.