Healthcare Provider Details

I. General information

NPI: 1265625818
Provider Name (Legal Business Name): SOUTHEASTERN OVERREAD SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MUIRS CHAPEL RD LOWER LEVEL
GREENSBORO NC
27410-6161
US

IV. Provider business mailing address

PO BOX 4778
GREENSBORO NC
27404-4778
US

V. Phone/Fax

Practice location:
  • Phone: 336-542-2903
  • Fax: 336-542-2929
Mailing address:
  • Phone: 336-542-2903
  • Fax: 336-542-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DALLAS A SMITH JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 336-542-2900