Provider Demographics
NPI:1831108802
Name:SOUTHEASTERN NEUROLOGY, PC
Entity Type:Organization
Organization Name:SOUTHEASTERN NEUROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SMARANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-421-6630
Mailing Address - Street 1:2 E CLARK BASS BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4210
Mailing Address - Country:US
Mailing Address - Phone:918-421-6630
Mailing Address - Fax:918-421-6631
Practice Address - Street 1:2 E CLARK BASS BLVD STE 305
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4210
Practice Address - Country:US
Practice Address - Phone:918-421-6630
Practice Address - Fax:918-421-6631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22154174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH92190Medicare UPIN