Basic Information
Provider Information | |||||||||
NPI: | 1730500489 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEAST ORTHOPEDIC SPECIALISTS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6500 BOWDEN RD | ||||||||
Address2: | SUITE 103 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322168070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9046340640 | ||||||||
FaxNumber: | 9046746155 | ||||||||
Practice Location | |||||||||
Address1: | 2300 PARK AVE | ||||||||
Address2: | SUITE 203 | ||||||||
City: | ORANGE PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 320735571 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9046340640 | ||||||||
FaxNumber: | 9046340203 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/26/2013 | ||||||||
LastUpdateDate: | 12/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DUFFY | ||||||||
AuthorizedOfficialFirstName: | GAVAN | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
AuthorizedOfficialTelephone: | 9046340640 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.