Provider Demographics
NPI:1124034509
Name:SOUTHEAST MEDICAL CENTER PC
Entity Type:Organization
Organization Name:SOUTHEAST MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-742-3267
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:OAKES
Mailing Address - State:ND
Mailing Address - Zip Code:58474-0050
Mailing Address - Country:US
Mailing Address - Phone:701-742-3267
Mailing Address - Fax:701-742-3201
Practice Address - Street 1:102 10TH AVENUE WEST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-1097
Practice Address - Country:US
Practice Address - Phone:701-683-2214
Practice Address - Fax:701-683-2130
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAT MEDICAL CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-31
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10336Medicaid
ND6638001OtherBLUE SHIELD
NDCF8850OtherRAILROAD MEDICARE
NDCF8850OtherRAILROAD MEDICARE
NDN70957Medicare Oscar/Certification
ND6638001OtherBLUE SHIELD