Provider Demographics
NPI:1972725414
Name:SOUTHEAST RADIOLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:SOUTHEAST RADIOLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-689-8702
Mailing Address - Street 1:618 VINTAGE WAY
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6366
Mailing Address - Country:US
Mailing Address - Phone:813-689-8702
Mailing Address - Fax:813-684-6392
Practice Address - Street 1:618 VINTAGE WAY
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6366
Practice Address - Country:US
Practice Address - Phone:813-689-8702
Practice Address - Fax:813-684-6392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94962Medicare UPIN
FL94962Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID