Basic Information
| Provider Information | |||||||||
| NPI: | 1124060678 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN OVERREAD SERVICES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16566 | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275166566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199676646 | ||||||||
| FaxNumber: | 9199676647 | ||||||||
| Practice Location | |||||||||
| Address1: | 3723 W MARKET ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274031590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368523488 | ||||||||
| FaxNumber: | 3368523442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DALLAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3368523488 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 013TR | 01 | NC | BLUE CROSS/BLUE SHIELD | OTHER | 89013TR | 05 | NC | MEDICAID |