Provider Demographics
NPI:1720419484
Name:SOUTHEASTERN INTEGRATED MEDICAL PL
Entity Type:Organization
Organization Name:SOUTHEASTERN INTEGRATED MEDICAL PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIBNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-493-1741
Mailing Address - Street 1:1315 NW 21ST AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-1977
Mailing Address - Country:US
Mailing Address - Phone:352-493-1741
Mailing Address - Fax:352-490-8641
Practice Address - Street 1:1315 NW 21ST AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-1977
Practice Address - Country:US
Practice Address - Phone:352-493-1741
Practice Address - Fax:352-490-8641
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEASTERN INTEGRATED MEDICAL PL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME688062081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058586600Medicaid
FL97749Medicare PIN