Basic Information
| Provider Information | |||||||||
| NPI: | 1205844586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST REGIONAL VIRTUAL IMAGING CONSULTING ENTERPRISE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52990 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296490048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642233600 | ||||||||
| FaxNumber: | 8642236054 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 STABLE GATE DR | ||||||||
| Address2: | |||||||||
| City: | CAMPOBELLO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293228037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644685570 | ||||||||
| FaxNumber: | 8644685239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | GORDIN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | JACOB | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8644685238 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 16566 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GP4506 | 05 | SC | MEDICAID |