Provider Demographics
NPI:1790009645
Name:SOUTHEAST UROLOGY LLC
Entity Type:Organization
Organization Name:SOUTHEAST UROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SALTZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-500-9920
Mailing Address - Street 1:3227 GLACIER HWY
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7842
Mailing Address - Country:US
Mailing Address - Phone:907-500-9920
Mailing Address - Fax:907-500-9932
Practice Address - Street 1:3227 GLACIER HWY
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7842
Practice Address - Country:US
Practice Address - Phone:907-500-9920
Practice Address - Fax:907-500-9932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5529208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1840Medicaid