Healthcare Provider Details

I. General information

NPI: 1346175114
Provider Name (Legal Business Name): SOUTHEASTERN PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12205 COUNTY LINE RD STE C
MADISON AL
35758-7720
US

IV. Provider business mailing address

12205 COUNTY LINE RD STE C
MADISON AL
35758-7720
US

V. Phone/Fax

Practice location:
  • Phone: 256-684-8247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: SHANE JONES
Title or Position: OWNER
Credential: DPM
Phone: 256-684-8247