Basic Information
| Provider Information | |||||||||
| NPI: | 1669414264 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN EMERGENCY SERVICES P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 634760 | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452634760 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1114 W MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237451411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | DABBS | ||||||||
| AuthorizedOfficialFirstName: | RANDAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8656931000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 363L00000X | TN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LP0200X | TN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2348298 | 05 | NC | MEDICAID | 05515899 | 05 | MS | MEDICAID | 507432003 | 05 | MO | MEDICAID | GP4818 | 05 | SC | MEDICAID | 02121280 | 05 | MS | MEDICAID | 529929400 | 05 | AL | MEDICAID | 78903671 | 05 | KY | MEDICAID | 06310389 | 05 | MS | MEDICAID | 7100010470 | 05 | KY | MEDICAID |