=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629782776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEBASTIAN INTERNAL MEDICINE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2023
-----------------------------------------------------
Last Update Date | 04/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1627 US HIGHWAY 1
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-3899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-388-2110
-----------------------------------------------------
Fax | 772-388-2426
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1627 US HIGHWAY 1
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-3899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-388-2110
-----------------------------------------------------
Fax | 772-388-2426
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MRS. MICHELLE BEAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-388-2110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------