Provider Demographics
NPI:1093970162
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 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:352-373-6338
Mailing Address - Fax:352-373-6144
Practice Address - Street 1:4881 NW 8TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4582
Practice Address - Country:US
Practice Address - Phone:352-224-2486
Practice Address - Fax:352-331-6550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEASTERN INTEGRATED MEDICAL PL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6591101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058586600Medicaid
FL97749Medicare PIN