Provider Demographics
NPI:1730500489
Name:SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC
Entity Type:Organization
Organization Name:SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-634-0640
Mailing Address - Street 1:6800 SOUTHPOINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8203
Mailing Address - Country:US
Mailing Address - Phone:904-634-0640
Mailing Address - Fax:904-674-6155
Practice Address - Street 1:2300 PARK AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5571
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:2013-12-26
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4080Medicare PIN
FL4185690002Medicare NSC