Basic Information
| Provider Information | |||||||||
| NPI: | 1689772220 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN HEART & VASCULAR CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 NORTHLINE AVE | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274087616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362737900 | ||||||||
| FaxNumber: | 3362738147 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 NORTHLINE AVE | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274087619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362737900 | ||||||||
| FaxNumber: | 3362738147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 01/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | BERRY | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3362737900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 790129F | 05 | NC | MEDICAID | 0129F | 01 | NC | BCBS NC | OTHER |