Basic Information
| Provider Information | |||||||||
| NPI: | 1871735019 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEASTERN REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SRMC-AUDIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 890860 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282890860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715000 | ||||||||
| FaxNumber: | 9106080269 | ||||||||
| Practice Location | |||||||||
| Address1: | 584 FARRINGDOM ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283582615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715014 | ||||||||
| FaxNumber: | 9106080269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2009 | ||||||||
| LastUpdateDate: | 12/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9106715090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | H0064 | NC | Y | Suppliers | Hearing Aid Equipment |
ID Information
| ID | Type | State | Issuer | Description | 7200273 | 05 | NC | MEDICAID | 3404235 | 05 | NC | MEDICAID |