MEDICARE: SOUTHEAST RADIOLOGY LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician	MD015422E	PA
2	2085R0202X	Diagnostic Radiology Physician	MD015422E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790779684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST RADIOLOGY LTD

Provider Business Mailing Address
First Line	:	PO BOX 3247
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47731-3247
Country	:	US
Telephone Number	:	800-467-2392
Fax Number	:	812-471-6650

Provider Business Practice Location Address
First Line	:	1 MEDICAL CENTER BLVD
Second Line	:
City	:	CHESTER
State	:	PA
Zip	:	19013-3902
Country	:	US
Telephone Number	:	610-447-2517
Fax Number	:	610-956-0069

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN HIEHLE
Credential	:	MD
Telephone Number	:	610-447-2500

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/07/2022

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Directions to “SOUTHEAST RADIOLOGY LTD ” Practice Location

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