Basic Information
| Provider Information | |||||||||
| NPI: | 1922340520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MADISON FAMILY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1230 SLAUGHTER RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MADISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357585900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567220555 | ||||||||
| FaxNumber: | 2568305135 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 SLAUGHTER RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MADISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357585900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567220555 | ||||||||
| FaxNumber: | 2568305135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2013 | ||||||||
| LastUpdateDate: | 03/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | BRUNO | ||||||||
| AuthorizedOfficialFirstName: | MARLEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2567220555 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.