Provider Demographics
NPI:1407848211
Name:SOUTHEASTERN OSTEOPOROSIS SERVICES INC
Entity Type:Organization
Organization Name:SOUTHEASTERN OSTEOPOROSIS SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAST
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:850-477-0775
Mailing Address - Street 1:4511 N DAVIS HWY
Mailing Address - Street 2:SUITE 1-C
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2720
Mailing Address - Country:US
Mailing Address - Phone:850-477-0775
Mailing Address - Fax:
Practice Address - Street 1:4511 N DAVIS HWY
Practice Address - Street 2:SUITE 1-C
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2720
Practice Address - Country:US
Practice Address - Phone:850-477-0775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJR34191002471B0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471B0102XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistBone DensitometryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3405722OtherUNITED HEALTH CARE
AL34252Medicaid
AL34252Medicare ID - Type Unspecified