Provider Demographics
NPI:1407967565
Name:SOUTHEASTERN MOBILE IMAGING LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN MOBILE IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-216-0618
Mailing Address - Street 1:1137 ANDREW BROOK LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-1591
Mailing Address - Country:US
Mailing Address - Phone:865-216-0618
Mailing Address - Fax:865-637-6376
Practice Address - Street 1:5004 BAYBERRY DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-1401
Practice Address - Country:US
Practice Address - Phone:865-216-0618
Practice Address - Fax:423-765-0465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNNA335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
3404564Medicare Oscar/Certification