1497784177 NPI number — SOUTHEAST MEDICAL IMAGING, LLC

Table of content: (NPI 1497784177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497784177 NPI number — SOUTHEAST MEDICAL IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST MEDICAL IMAGING, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE VEIN CENTER AT BRINTON LAKE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497784177
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 78
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47701-0078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-579-3500
Provider Business Mailing Address Fax Number:
610-579-3501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 EVERGREEN DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
GLEN MILLS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19342-1059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-579-3500
Provider Business Practice Location Address Fax Number:
610-579-3501
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUETTERTIES
Authorized Official First Name:
KURT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
610-579-3505

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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