Provider Demographics
NPI:1326046418
Name:SOUTHEAST INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:SOUTHEAST INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:MCQUISTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-671-5100
Mailing Address - Street 1:29159 HELMAN
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-0172
Mailing Address - Country:US
Mailing Address - Phone:734-671-5100
Mailing Address - Fax:734-671-7664
Practice Address - Street 1:29159 HELMAN BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN
Practice Address - State:MI
Practice Address - Zip Code:48183
Practice Address - Country:US
Practice Address - Phone:734-671-5100
Practice Address - Fax:734-671-7664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012342207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4323064Medicaid
MI4439990Medicaid
MI0N33780Medicare PIN