MEDICARE: SOUTHEASTERN IMAGING ASSOCIATES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center	HCC8538	FL

General Provider Information

NPI Number	:	1780828814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN IMAGING ASSOCIATES INC

Provider Business Mailing Address
First Line	:	8461 LAKE WORTH RD
Second Line	:	SUITE 235
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-2474
Country	:	US
Telephone Number	:	561-422-3372
Fax Number	:	561-422-3377

Provider Business Practice Location Address
First Line	:	8461 LAKE WORTH RD
Second Line	:	SUITE 235
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-2474
Country	:	US
Telephone Number	:	561-422-3372
Fax Number	:	561-422-3377

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RONALD ENRIQUE GONZALEZ
Credential	:	RDMS, RDCS, RVT
Telephone Number	:	954-325-3911

Provider Enumeration Date	:	04/20/2009
Last Update Date	:	01/18/2013

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