Basic Information
| Provider Information | |||||||||
| NPI: | 1821068891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN PLASTIC SURGERY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 649 N NEW HOPE RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280547424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048664005 | ||||||||
| FaxNumber: | 7048660450 | ||||||||
| Practice Location | |||||||||
| Address1: | 649 N NEW HOPE RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280547424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048664005 | ||||||||
| FaxNumber: | 7048660450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 08/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | TIMMONS | ||||||||
| AuthorizedOfficialFirstName: | BENSON | ||||||||
| AuthorizedOfficialMiddleName: | EL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7048664005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0269X | 01 | NC | BCBS | OTHER | 890269X | 05 | NC | MEDICAID |