Basic Information
| Provider Information | |||||||||
| NPI: | 1255762928 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN INTEGRATED MEDICAL PL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3305 SW 34TH CIR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344746616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527324438 | ||||||||
| FaxNumber: | 3527320028 | ||||||||
| Practice Location | |||||||||
| Address1: | 3305 SW 34TH CIR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344746616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527324438 | ||||||||
| FaxNumber: | 3527320028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2013 | ||||||||
| LastUpdateDate: | 12/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | CLUNN | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3527324438 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEASTERN INTEGRATED MEDICAL PL | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | ME86226 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 058586600 | 05 | FL | MEDICAID |