Provider Demographics
NPI:1467630616
Name:SOUTHEASTERN ORTHOPEDICS PC
Entity type:Organization
Organization Name:SOUTHEASTERN ORTHOPEDICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SOMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-265-0229
Mailing Address - Street 1:770 RIVERSIDE AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1476
Mailing Address - Country:US
Mailing Address - Phone:517-265-5230
Mailing Address - Fax:517-265-1535
Practice Address - Street 1:770 RIVERSIDE AVE
Practice Address - Street 2:STE 105
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1476
Practice Address - Country:US
Practice Address - Phone:517-265-5230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4180319Medicaid
MI2004611141OtherBCBS
MI0N90120Medicare PIN