Provider Demographics
NPI:1669476453
Name:SOUTHEASTERN RADIOLOGY PA
Entity Type:Organization
Organization Name:SOUTHEASTERN RADIOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:336-852-3300
Mailing Address - Street 1:3801 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1301
Mailing Address - Country:US
Mailing Address - Phone:336-852-3300
Mailing Address - Fax:336-852-0651
Practice Address - Street 1:3801 W MARKET ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1301
Practice Address - Country:US
Practice Address - Phone:336-852-3300
Practice Address - Fax:336-852-0651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4005552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890252KMedicaid
NC890252KMedicaid