Healthcare Provider Details

I. General information

NPI: 1457093361
Provider Name (Legal Business Name): HUGHSTON ORTHOPAEDIC SOUTHEAST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 SPYGLASS HILL RD STE 104
MELBOURNE FL
32940-8567
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 407-595-4389
  • Fax: 407-346-5614
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: AMANDA FROMKIN
Title or Position: CREDENTIALING MGR
Credential:
Phone: 706-494-3071