NPIMap

Organization Active NPI

Southeastern Integrated Medical PL

  • Pain Medicine (Physical Medicine & Rehabilitation) Physician
  • Chiefland, FL
National Provider Identifier
1720419484
Registry record updated Dec 6, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Medicine (Physical Medicine & Rehabilitation) PhysicianTaxonomy code 2081P2900X
License
ME68806 Issued in FL
Legal business name
SOUTHEASTERN INTEGRATED MEDICAL PL
Practice address
1315 NW 21St Ave
Suite 2
Chiefland, FL 32626-1977
Phone
(352) 493-1741
Fax
(352) 490-8641
NPI assigned
Dec 6, 2013
Organization subpart
Yes
Parent organization
SOUTHEASTERN INTEGRATED MEDICAL PLAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 6, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jesse A Libnick, M.D.
Title
Physician
Phone
(352) 493-1741

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pain Medicine (Physical Medicine & Rehabilitation) PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2081P2900X ME68806 FL Primary

Addresses

Primary practice location

1315 NW 21St Ave
Suite 2
Chiefland, FL 32626-1977

Mailing address

1315 NW 21St Ave
Suite 2
Chiefland, FL 32626-1977
Phone (352) 493-1741

Other identifiers 1

IdentifierTypeStateIssuer
058586600MedicaidFL

National Provider Directory

National Provider Directory
Tax ID family
Southeastern Integrated Medical PL5 organizations share this tax ID, including this one
Part of
Southeastern Integrated Medical PL

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1315 NW 21st Ave
Ste 2
Chiefland, FL 32626
Phone (352) 493-1741

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1386288000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1386288000000",
    "number": "1720419484",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1315 NW 21ST AVE",
            "address_2": "SUITE 2",
            "city": "CHIEFLAND",
            "state": "FL",
            "postal_code": "326261977",
            "telephone_number": "352-493-1741",
            "fax_number": "352-490-8641"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1315 NW 21ST AVE",
            "address_2": "SUITE 2",
            "city": "CHIEFLAND",
            "state": "FL",
            "postal_code": "326261977",
            "telephone_number": "352-493-1741",
            "fax_number": "352-490-8641"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEASTERN INTEGRATED MEDICAL PL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHEASTERN INTEGRATED MEDICAL PL",
        "enumeration_date": "2013-12-06",
        "last_updated": "2013-12-06",
        "status": "A",
        "authorized_official_last_name": "LIBNICK",
        "authorized_official_first_name": "JESSE",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "352-493-1741",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "2081P2900X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": "FL",
            "license": "ME68806",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "058586600",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Chiefland, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 6, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.