Organization
SOUTHEASTERN REGIONAL MEDICAL CENTER
Active
Other names
Fairmont Medical Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES THOMAS JOHNSON III (VICE PRESIDENT FINANCE)
(910) 671-5090
Entity
Organization
Contact information
Practice address
101 N WALNUT ST, FAIRMONT, NC 28340-1951
(910) 628-0655
(910) 628-0158
Mailing address
2600 N ELM ST, LUMBERTON, NC 28358-3011
(910) 272-3051
(910) 738-3764
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
H0064
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0260K
BLUE CROSS BLUE SHIELD
NC
05
—
343989A
—
NC
05
—
343989C
—
NC
Enumeration date
06/14/2005
Last updated
01/27/2009
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