Provider Demographics
NPI:1134303621
Name:SOUTHEASTERN FAMILY PRACTICE SC
Entity Type:Organization
Organization Name:SOUTHEASTERN FAMILY PRACTICE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NOEMI
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRIETO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-463-6640
Mailing Address - Street 1:8532 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1848
Mailing Address - Country:US
Mailing Address - Phone:414-463-6640
Mailing Address - Fax:414-463-6743
Practice Address - Street 1:1308 S 16TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2711
Practice Address - Country:US
Practice Address - Phone:414-831-0100
Practice Address - Fax:414-831-1584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48505207R00000X
WI265292080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30718400Medicaid