MEDICARE: SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	208VP0014X	Interventional Pain Medicine Physician
2	208VP0000X	Pain Medicine Physician
3	213E00000X	Podiatrist
4	174400000X	Specialist
5	207XS0106X	Orthopaedic Hand Surgery Physician
6	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician
7	207QS0010X	Sports Medicine (Family Medicine) Physician
8	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician
9	207XX0801X	Orthopaedic Trauma Physician
10	207XS0114X	Adult Reconstructive Orthopaedic Surgery Physician
11	207X00000X	Orthopaedic Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629025820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC

Provider Business Mailing Address
First Line	:	6800 SOUTHPOINT PKWY STE 300
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8203
Country	:	US
Telephone Number	:	904-634-0640
Fax Number	:	904-634-0203

Provider Business Practice Location Address
First Line	:	2627 RIVERSIDE AVE FL 3
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4717
Country	:	US
Telephone Number	:	904-634-0640
Fax Number	:	904-634-0203

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	BRETT PUCKETT
Credential	:	MD
Telephone Number	:	904-634-0640

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	12/09/2025

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