Basic Information
| Provider Information | |||||||||
| NPI: | 1760534358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN SPINE INSTITUTE,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 CHUCK DAWLEY BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294644183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438491551 | ||||||||
| FaxNumber: | 8438496591 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 HOSPITAL DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294643698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438491551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8438638542 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | GP3652 | 05 | SC | MEDICAID | 20093922 | 01 | SC | TRICARE | OTHER | DA0067 | 01 | SC | MEDICARE RAILROAD | OTHER | 4861350002 | 01 | MEDICARE DMERC | OTHER |