Provider Demographics
NPI:1306060504
Name:SOUTHEASTERN CLINICAL INC
Entity type:Organization
Organization Name:SOUTHEASTERN CLINICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-423-6791
Mailing Address - Street 1:PO BOX 21568
Mailing Address - Street 2:DEPT 148
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-1568
Mailing Address - Country:US
Mailing Address - Phone:405-947-8584
Mailing Address - Fax:405-948-6507
Practice Address - Street 1:716 E WYANDOTTE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5428
Practice Address - Country:US
Practice Address - Phone:918-423-6791
Practice Address - Fax:405-948-6507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBCBS
E82945Medicare UPIN