Provider Demographics
NPI:1114302692
Name:SOUTHEASTERN PSYCHIATRIC SERVICES
Entity Type:Organization
Organization Name:SOUTHEASTERN PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:918-423-3700
Mailing Address - Street 1:100 S MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5369
Mailing Address - Country:US
Mailing Address - Phone:918-423-3700
Mailing Address - Fax:
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5369
Practice Address - Country:US
Practice Address - Phone:918-423-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0058049251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100747990AMedicaid