Provider Demographics
NPI:1508387697
Name:HUGHSTON CLINIC SOUTHEAST PC
Entity Type:Organization
Organization Name:HUGHSTON CLINIC SOUTHEAST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
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 1:6262 VETERANS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-3540
Mailing Address - Country:US
Mailing Address - Phone:706-494-3071
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:631 PROFESSIONAL DR STE 170
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3392
Practice Address - Country:US
Practice Address - Phone:678-312-2663
Practice Address - Fax:770-962-8587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-29
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies