Healthcare Provider Details

I. General information

NPI: 1912146853
Provider Name (Legal Business Name): SOUTHEASTERN INTEGRATED MEDICAL PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 SW 34TH CIR
OCALA FL
34474-3358
US

IV. Provider business mailing address

4881 NW 8TH AVENUE STE 2
GAINESVILLE FL
32605-4582
US

V. Phone/Fax

Practice location:
  • Phone: 352-732-4438
  • Fax: 352-291-0231
Mailing address:
  • Phone: 352-373-6338
  • Fax: 352-373-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. JESSE C BRANNEN
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 352-224-2200