Organization
SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES T. JOHNSON III (CFO)
(910) 671-5090
Entity
Organization
Contact information
Practice address
2002 N CEDAR ST STE B, LUMBERTON, NC 28358-3926
(910) 272-3048
(910) 738-3764
Mailing address
2002 N CEDAR ST STE B, LUMBERTON, NC 28358-3926
(910) 272-3048
(910) 738-3764
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
H0064
NC
261QR1300X
Rural Health Clinic/Center
H0064
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
022WG
BCBS
NC
01
—
022WN
BCBS
NC
01
—
022WP
BCBS
NC
01
—
022WR
BCBS
NC
01
—
022WT
BCBS
NC
01
—
022WU
BCBS
NC
01
—
023R1
BCBS
NC
01
—
025F5
BCBS
NC
05
—
344638A
—
NC
05
—
344638C
—
NC
05
—
344639A
—
NC
05
—
344639C
—
NC
05
—
344641A
—
NC
05
—
344641C
—
NC
05
—
344642A
—
NC
05
—
344642C
—
NC
05
—
344647A
—
NC
05
—
344647C
—
NC
05
—
348954A
—
NC
05
—
348954C
—
NC
05
—
348961A
—
NC
05
—
348961C
—
NC
05
—
5913422
—
NC
05
—
5914043
—
NC
05
—
5914044
—
NC
05
—
5914045
—
NC
05
—
5914047
—
NC
05
—
5914048
—
NC
05
—
5914049
—
NC
05
—
5914050
—
NC
05
—
5914051
—
NC
05
—
5914168
—
NC
05
—
5914429
—
NC
05
—
5916164
—
NC
05
—
5917135
—
NC
05
—
5917396
—
NC
05
—
5917766
—
NC
05
—
5917954
—
NC
05
—
5918279
—
NC
05
—
5921524
—
NC
Enumeration date
05/11/2009
Last updated
10/08/2020
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