Basic Information
| Provider Information | |||||||||
| NPI: | 1295156941 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST ORTHOPEDIC SPECIALISTS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6500 BOWDEN RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322168070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046746155 | ||||||||
| Practice Location | |||||||||
| Address1: | 10475 CENTURION PKWY N STE 220 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322565004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046746155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2013 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | PUCKETT | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/AUTHORIZED | ||||||||
| AuthorizedOfficialTelephone: | 9043490290 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 74895 | 01 | FL | BCBS | OTHER |