Healthcare Provider Details

I. General information

NPI: 1497784177
Provider Name (Legal Business Name): SOUTHEAST MEDICAL IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 EVERGREEN DR SUITE 210
GLEN MILLS PA
19342-1059
US

IV. Provider business mailing address

PO BOX 78
EVANSVILLE IN
47701-0078
US

V. Phone/Fax

Practice location:
  • Phone: 610-579-3500
  • Fax: 610-579-3501
Mailing address:
  • Phone: 610-579-3500
  • Fax: 610-579-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KURT A MUETTERTIES
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 610-579-3505