Provider Demographics
NPI:1861872657
Name:SOUTHEAST RADIOLOGY CONSULTANTS LLC
Entity type:Organization
Organization Name:SOUTHEAST RADIOLOGY CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-321-1953
Mailing Address - Street 1:3260 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7808
Mailing Address - Country:US
Mailing Address - Phone:907-796-8631
Mailing Address - Fax:
Practice Address - Street 1:3260 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7808
Practice Address - Country:US
Practice Address - Phone:907-796-8631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK55332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1014647Medicaid