Provider Demographics
NPI:1912146853
Name:SOUTHEASTERN INTEGRATED MEDICAL PL
Entity Type:Organization
Organization Name:SOUTHEASTERN INTEGRATED MEDICAL PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRANNEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-224-2200
Mailing Address - Street 1:4881 NW 8TH AVENUE
Mailing Address - Street 2:STE 2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4582
Mailing Address - Country:US
Mailing Address - Phone:352-373-6338
Mailing Address - Fax:352-373-6144
Practice Address - Street 1:3304 SW 34TH CIR
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-3358
Practice Address - Country:US
Practice Address - Phone:352-732-4438
Practice Address - Fax:352-291-0231
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEASTERN INTEGRATED MEDICAL PL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058586600Medicaid
FL97749Medicare PIN