Provider Demographics
NPI:1457483612
Name:SOUTHEASTERN PEDIATRIC & ADOLESCENT MEDICINE, S.C.
Entity Type:Organization
Organization Name:SOUTHEASTERN PEDIATRIC & ADOLESCENT MEDICINE, S.C.
Other - Org Name:SOUTHEASTERN PEDIATRIC & ADOLESCENT MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DELTORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-463-2607
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:414-463-2607
Mailing Address - Fax:414-463-6743
Practice Address - Street 1:8532 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1848
Practice Address - Country:US
Practice Address - Phone:414-463-2607
Practice Address - Fax:414-463-6743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32787700Medicaid