Provider Demographics
NPI:1083715262
Name:SOUTHEAST UROLOGY CLINIC A PC
Entity Type:Organization
Organization Name:SOUTHEAST UROLOGY CLINIC A PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SAMTMANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-424-7991
Mailing Address - Street 1:1311 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274
Mailing Address - Country:US
Mailing Address - Phone:360-424-7991
Mailing Address - Fax:360-424-5441
Practice Address - Street 1:3100 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5746
Practice Address - Country:US
Practice Address - Phone:907-225-1896
Practice Address - Fax:360-428-4377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK121467208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKGR0126Medicaid
AKGR0126Medicaid