Provider Demographics
NPI:1700099017
Name:SOUTHEASTERN NEUROSCIENCE INSTITUTE PA
Entity Type:Organization
Organization Name:SOUTHEASTERN NEUROSCIENCE INSTITUTE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, NEUROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:904-346-0707
Mailing Address - Street 1:3728 PHILLIPS HWY
Mailing Address - Street 2:SUITE 32
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-9300
Mailing Address - Country:US
Mailing Address - Phone:904-346-0707
Mailing Address - Fax:904-396-4300
Practice Address - Street 1:3728 PHILLIPS HWY
Practice Address - Street 2:SUITE 31
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9300
Practice Address - Country:US
Practice Address - Phone:904-346-0707
Practice Address - Fax:904-396-4300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0013636174400000X
FLME 59265174400000X
FLME45606174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059852600Medicaid
FL380447000Medicaid
FL266403800Medicaid
FL046597600Medicare ID - Type UnspecifiedDR. LEONBARTH
FLD57880Medicare UPIN
FLT94415Medicare UPIN
FLD45481Medicare UPIN
FL70395ZMedicare ID - Type UnspecifiedDR. FRALICKER
FL68370Medicare ID - Type UnspecifiedDR. WARNER
FL059852600Medicaid
FL380447000Medicaid
FL266403800Medicaid