Provider Demographics
NPI:1154765410
Name:SOUTHEASTERN PEDIATRICS, SC
Entity type:Organization
Organization Name:SOUTHEASTERN PEDIATRICS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RATIDZAI
Authorized Official - Middle Name:
Authorized Official - Last Name:RIOGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-771-0500
Mailing Address - Street 1:7592 SOLUTIONS CTR # 777592
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-7005
Mailing Address - Country:US
Mailing Address - Phone:262-641-3700
Mailing Address - Fax:262-641-3719
Practice Address - Street 1:10625 W NORTH AVE STE 326
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2315
Practice Address - Country:US
Practice Address - Phone:414-771-0500
Practice Address - Fax:414-771-0363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41265207Q00000X, 2080A0000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty