Provider Demographics
NPI:1871059212
Name:SOUTHEAST MEDICAL GROUP LLC
Entity type:Organization
Organization Name:SOUTHEAST MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-308-3183
Mailing Address - Street 1:1930 EDWARDS LAKE RD STE 138
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3720
Mailing Address - Country:US
Mailing Address - Phone:205-534-5114
Mailing Address - Fax:205-278-6939
Practice Address - Street 1:1930 EDWARDS LAKE RD STE 138B
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3720
Practice Address - Country:US
Practice Address - Phone:205-308-3183
Practice Address - Fax:205-278-6939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty