Provider Demographics
NPI:1497784177
Name:SOUTHEAST MEDICAL IMAGING, LLC
Entity Type:Organization
Organization Name:SOUTHEAST MEDICAL IMAGING, LLC
Other - Org Name:THE VEIN CENTER AT BRINTON LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUETTERTIES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-579-3505
Mailing Address - Street 1:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47701-0078
Mailing Address - Country:US
Mailing Address - Phone:610-579-3500
Mailing Address - Fax:610-579-3501
Practice Address - Street 1:300 EVERGREEN DR
Practice Address - Street 2:SUITE 210
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-1059
Practice Address - Country:US
Practice Address - Phone:610-579-3500
Practice Address - Fax:610-579-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
092801Medicare ID - Type Unspecified