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General NPI Number Information
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NPI Number | 1720419484
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN INTEGRATED MEDICAL PL
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Dates
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Enumeration Date | 12/06/2013
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Last Update Date | 12/06/2013
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Provider Practice Location Address
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Address Line | 1315 NW 21ST AVE SUITE 2
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City | CHIEFLAND
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State | FL
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Zip | 32626-1977
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Country | US
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Telephone | 352-493-1741
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Fax | 352-490-8641
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Provider Business Mailing Address
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Address Line | 1315 NW 21ST AVE SUITE 2
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City | CHIEFLAND
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State | FL
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Zip | 32626-1977
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Country | US
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Telephone | 352-493-1741
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Fax | 352-490-8641
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Authorized Official
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Title or Position | PHYSICIAN
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Name | JESSE A LIBNICK
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Credential | M.D.
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Telephone | 352-493-1741
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | ME68806
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License Number State | FL
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