| Organization Name: | SOUTHEASTERN MEDICAL GROUP, INC |
| NPI Number: | 1083074314 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SANDRA MILENA ZERVOUDAKIS (EXECUTIVE DIRECTOR) |
| Mailing Address: | 1881 Ne 26th St Suite 224 Wilton Manors |
| State: | FL US |
| Postal Code: | 333051416 |
| Phone Number: | 9543981947 |
| Fax Number: | |
| NPI Enumeration Date: | 02/29/2016 |
| NPI Last Update Date: | 02/29/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP0808X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Psych/Mental Health |
| Taxonomy Definition: | |