Provider Demographics
| NPI: | 1871573949 |
|---|---|
| Name: | SOUTHEASTERN INTEGRATED MEDICAL PL |
| Entity type: | Organization |
| Organization Name: | SOUTHEASTERN INTEGRATED MEDICAL PL |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CHEIF EXECUTIVE OFFICER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | DANIEL |
| Authorized Official - Middle Name: | M |
| Authorized Official - Last Name: | DUNCANSON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD,CPE |
| Authorized Official - Phone: | 352-224-2200 |
| Mailing Address - Street 1: | 4881 NW 8TH AVE |
| Mailing Address - Street 2: | SUITE 2 |
| Mailing Address - City: | GAINESVILLE |
| Mailing Address - State: | FL |
| Mailing Address - Zip Code: | 32605-4582 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 352-547-2373 |
| Mailing Address - Fax: | 352-416-1813 |
| Practice Address - Street 1: | 4343 W NEWBERRY RD |
| Practice Address - Street 2: | |
| Practice Address - City: | GAINESVILLE |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 32607-2817 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 352-224-2200 |
| Practice Address - Fax: | 352-224-2484 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | SOUTHEASTERN INTEGRATED MEDICAL PL |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-01-17 |
| Last Update Date: | 2015-03-09 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 204D00000X | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | Group - Multi-Specialty | |
| No | 207KA0200X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | Group - Multi-Specialty |
| No | 207KI0005X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Clinical & Laboratory Immunology | Group - Multi-Specialty |
| No | 207NS0135X | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | Group - Multi-Specialty |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0001X | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | Group - Multi-Specialty |
| No | 207RM1200X | Allopathic & Osteopathic Physicians | Internal Medicine | Magnetic Resonance Imaging (MRI) | Group - Multi-Specialty |
| No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207U00000X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207VG0400X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | Group - Multi-Specialty |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207YS0123X | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| FL | 058586600 | Medicaid | |
| FL | 97749 | Medicare PIN | |
| FL | 5676710002 | Medicare NSC |
