Healthcare Provider Details

I. General information

NPI: 1619277688
Provider Name (Legal Business Name): SOUTHEASTERN MEDICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W MAIN ST STE 205
NORMAN OK
73069-6824
US

IV. Provider business mailing address

PO BOX 722606
NORMAN OK
73070-8981
US

V. Phone/Fax

Practice location:
  • Phone: 405-292-5500
  • Fax: 405-292-5505
Mailing address:
  • Phone: 405-292-5500
  • Fax: 405-292-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number16862
License Number StateOK

VIII. Authorized Official

Name: STEPHEN RIDDEL
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 405-292-5500