Provider Demographics
NPI:1558757765
Name:SOUTHEAST UROLOGY, LLC
Entity Type:Organization
Organization Name:SOUTHEAST UROLOGY, LLC
Other - Org Name:SALMON CREEK SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:STANFILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-223-0515
Mailing Address - Street 1:3225 HOSPITAL DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7863
Mailing Address - Country:US
Mailing Address - Phone:907-500-9920
Mailing Address - Fax:253-927-5472
Practice Address - Street 1:3225 HOSPITAL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7863
Practice Address - Country:US
Practice Address - Phone:907-500-9920
Practice Address - Fax:253-927-5472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical