NPIMap

Organization Active NPI

Southeastern Specialist Clinic

  • Specialist
  • Gastonia, NC
National Provider Identifier
1487632873
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
19633 Issued in NC
Legal business name
SOUTHEASTERN SPECIALIST CLINIC
Practice address
825 Majestic CT
Suite F
Gastonia, NC 28054-5186
Phone
(704) 867-8975
Fax
(704) 867-8353
NPI assigned
Jan 5, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John R. Miles Jr., M.D.
Title
President/Owner
Phone
(704) 867-8975

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X 19633 NC Primary

Addresses

Primary practice location

825 Majestic CT
Suite F
Gastonia, NC 28054-5186

Mailing address

825 Majestic Court
Suite F
Gastonia, NC 28054
Phone (704) 867-8975

Other identifiers 1

IdentifierTypeStateIssuer
8958807MedicaidNC

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1136419200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1487632873",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "825 MAJESTIC COURT",
            "address_2": "SUITE F",
            "city": "GASTONIA",
            "state": "NC",
            "postal_code": "28054",
            "telephone_number": "704-867-8975",
            "fax_number": "704-867-8353"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "825 MAJESTIC CT",
            "address_2": "SUITE F",
            "city": "GASTONIA",
            "state": "NC",
            "postal_code": "280545186",
            "telephone_number": "704-867-8975",
            "fax_number": "704-867-8353"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEASTERN SPECIALIST CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-01-05",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "MILES",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "R.",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "704-867-8975",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "NC",
            "license": "19633",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8958807",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Gastonia, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.