Provider Demographics
NPI:1730500497
Name:SOUTHEAST ORTHOPEDIC SPECIALISTS, INC.
Entity Type:Organization
Organization Name:SOUTHEAST ORTHOPEDIC SPECIALISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:GAVAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUFFY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-634-0640
Mailing Address - Street 1:6500 BOWDEN RD
Mailing Address - Street 2:SUITE 103
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:904-634-0203
Practice Address - Street 1:1658 ST VINCENTS WAY STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8447
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:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4080Medicare PIN
FL4185690005Medicare NSC