Basic Information
| Provider Information | |||||||||
| NPI: | 1730204736 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN CLINICAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 E CLARK BASS BLVD | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745014209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059478584 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 E CLARK BASS BLVD | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745014209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059478584 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JUDGE | ||||||||
| AuthorizedOfficialFirstName: | RICKY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4059478584 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 17491 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.