Basic Information
| Provider Information | |||||||||
| NPI: | 1154765410 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN PEDIATRICS, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7592 SOLUTIONS CTR # 777592 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606777005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626413700 | ||||||||
| FaxNumber: | 2626413719 | ||||||||
| Practice Location | |||||||||
| Address1: | 10625 W NORTH AVE STE 326 | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532262315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147710500 | ||||||||
| FaxNumber: | 4147710363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2013 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | RIOGA | ||||||||
| AuthorizedOfficialFirstName: | RATIDZAI | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4147710500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 41265 | WI | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2080A0000X | 41265 | WI | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.