Basic Information
| Provider Information | |||||||||
| NPI: | 1619277688 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN MEDICAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 722606 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730708981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052925500 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 W MAIN ST | ||||||||
| Address2: | STE 205 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730696824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052925500 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 10/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | RIDDEL | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4052925500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 16862 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.