Provider Demographics
NPI:1346858149
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:
Mailing Address - Fax:
Practice Address - Street 1:4689 HWY 17
Practice Address - Street 2:STE 12
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4831
Practice Address - Country:US
Practice Address - Phone:904-375-8850
Practice Address - Fax:904-458-4819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-17
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGOtherMEDICARE PTAN