Provider Demographics
NPI:1265044838
Name:HUGHSTON CLINIC SOUTHEAST, PC
Entity Type:Organization
Organization Name:HUGHSTON CLINIC SOUTHEAST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FROMKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-494-3071
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:706-494-3008
Mailing Address - Fax:
Practice Address - Street 1:3443 DICKERSON PIKE STE 190
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37207-2533
Practice Address - Country:US
Practice Address - Phone:615-301-8269
Practice Address - Fax:615-712-9823
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HUGHSTON CLINIC SOUTHEAST, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100579610Medicaid