Provider Demographics
NPI:1053367615
Name:SOUTHEASTERN ORTHOPEDICS SPORTS MEDICINE & SHOULDER CENTER PA
Entity type:Organization
Organization Name:SOUTHEASTERN ORTHOPEDICS SPORTS MEDICINE & SHOULDER CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SPEER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-256-1511
Mailing Address - Street 1:3404 WAKE FOREST RD
Mailing Address - Street 2:STE 201
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7341
Mailing Address - Country:US
Mailing Address - Phone:919-256-1511
Mailing Address - Fax:919-256-1530
Practice Address - Street 1:3404 WAKE FOREST RD
Practice Address - Street 2:STE 201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7341
Practice Address - Country:US
Practice Address - Phone:919-256-1511
Practice Address - Fax:919-256-1530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
154156200OtherUS DEPT OF LABOR
NC89015W4OtherMEDICAID
NC015W4OtherBCBS
NC89015W4OtherMEDICAID