Provider Demographics
NPI:1184764524
Name:SOUTHEAST OBSTETRICS & GYNECOLOGY PC
Entity type:Organization
Organization Name:SOUTHEAST OBSTETRICS & GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:TSHIBANGU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-256-3000
Mailing Address - Street 1:990 SOUTH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620
Mailing Address - Country:US
Mailing Address - Phone:585-256-3000
Mailing Address - Fax:
Practice Address - Street 1:990 SOUTH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2740
Practice Address - Country:US
Practice Address - Phone:585-256-3000
Practice Address - Fax:585-256-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty