Healthcare Provider Details

I. General information

NPI: 1154765410
Provider Name (Legal Business Name): SOUTHEASTERN PEDIATRICS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10625 W NORTH AVE STE 326
WAUWATOSA WI
53226-2315
US

IV. Provider business mailing address

7592 SOLUTIONS CTR # 777592
CHICAGO IL
60677-7005
US

V. Phone/Fax

Practice location:
  • Phone: 414-771-0500
  • Fax: 414-771-0363
Mailing address:
  • Phone: 262-641-3700
  • Fax: 262-641-3719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number41265
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41265
License Number StateWI

VIII. Authorized Official

Name: RATIDZAI RIOGA
Title or Position: PRESIDENT
Credential: MD
Phone: 414-771-0500