Healthcare Provider Details

I. General information

NPI: 1467435693
Provider Name (Legal Business Name): SOUTHEASTERN RADIOLOGY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E CLARK BASS BLVD
MCALESTER OK
74501-4209
US

IV. Provider business mailing address

PO BOX 758
MCALESTER OK
74502-0758
US

V. Phone/Fax

Practice location:
  • Phone: 918-423-3602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PHILIP MALONE
Title or Position: ADMINISTRATIVE MANGER
Credential:
Phone: 405-321-8125