Basic Information
| Provider Information | |||||||||
| NPI: | 1093970162 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN INTEGRATED MEDICAL PL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4881 NW 8TH AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523736338 | ||||||||
| FaxNumber: | 3523736144 | ||||||||
| Practice Location | |||||||||
| Address1: | 4881 NW 8TH AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522242486 | ||||||||
| FaxNumber: | 3523316550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 07/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRANNEN | ||||||||
| AuthorizedOfficialFirstName: | JESSE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3522242200 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEASTERN INTEGRATED MEDICAL PL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PY6591 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 058586600 | 05 | FL | MEDICAID |