Provider Demographics
NPI:1871798348
Name:SOUTHEAST MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:SOUTHEAST MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INS CLERK
Authorized Official - Prefix:MS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-215-5102
Mailing Address - Street 1:1301 48TH AVE N STE B
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5427
Mailing Address - Country:US
Mailing Address - Phone:843-215-5102
Mailing Address - Fax:843-215-5226
Practice Address - Street 1:1301 48TH AVE N STE B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5427
Practice Address - Country:US
Practice Address - Phone:843-215-5102
Practice Address - Fax:843-215-5226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7149Medicare ID - Type Unspecified