Basic Information
| Provider Information | |||||||||
| NPI: | 1659531952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN REGIONAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | SRMC-HOSPITALIST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W 27TH ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 W 27TH ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2008 | ||||||||
| LastUpdateDate: | 06/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9106715090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | H0064 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 020VX | 01 | NC | BCBS | OTHER | 5950154 | 05 | NC | MEDICAID |