Basic Information
| Provider Information | |||||||||
| NPI: | 1871573949 | ||||||||
| 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: | 3525472373 | ||||||||
| FaxNumber: | 3524161813 | ||||||||
| Practice Location | |||||||||
| Address1: | 4343 W NEWBERRY RD | ||||||||
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| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326072817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522242200 | ||||||||
| FaxNumber: | 3522242484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | DUNCANSON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHEIF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3522242200 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEASTERN INTEGRATED MEDICAL PL | ||||||||
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| AuthorizedOfficialCredential: | M.D.,C.P.E. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 207KI0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Clinical & Laboratory Immunology | 207NS0135X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RM1200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Magnetic Resonance Imaging (MRI) | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207U00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207YS0123X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | 204D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
ID Information
| ID | Type | State | Issuer | Description | 058586600 | 05 | FL | MEDICAID |