Provider Demographics
NPI:1003244658
Name:SOUTHEAST ORTHOPEDIC SPECIALISTS, INC
Entity Type:Organization
Organization Name:SOUTHEAST ORTHOPEDIC SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:JAGUNIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-634-0640
Mailing Address - Street 1:6500 BOWDEN RD
Mailing Address - Street 2:SUITE103
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8070
Mailing Address - Country:US
Mailing Address - Phone:904-634-0640
Mailing Address - Fax:904-674-6155
Practice Address - Street 1:2627 RIVERSIDE AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4712
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:904-634-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-17
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY90VCOtherBCBS
FLK4080Medicare PIN