Basic Information
| Provider Information | |||||||||
| NPI: | 1700210606 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN ORTHOPAEDIC SPECIALISTS, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPORTS MEDICINE & JOINT REPLACEMENT OF GREENSBORO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 E WENDOVER AVE | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363752300 | ||||||||
| FaxNumber: | 3363752314 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 N CHURCH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363752300 | ||||||||
| FaxNumber: | 3363752314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2013 | ||||||||
| LastUpdateDate: | 01/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | WAINER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3363752300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | BL 6497209 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.