Healthcare Provider Details

I. General information

NPI: 1902328727
Provider Name (Legal Business Name): SOUTHEAST IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FOREST AVE. SUITE C
EUFAULA OK
74432
US

IV. Provider business mailing address

3330 NW 56TH ST. SUITE 206
OKLAHOMA CITY OK
73112
US

V. Phone/Fax

Practice location:
  • Phone: 405-945-4710
  • Fax: 405-945-4751
Mailing address:
  • Phone: 405-945-4710
  • Fax: 405-945-4751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMIAH AARON JANSEN
Title or Position: MEMBER
Credential: M.D.
Phone: 405-249-7672