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General NPI Number Information
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NPI Number | 1245427525
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN PODIATRY CLINIC PA
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Dates
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Enumeration Date | 10/01/2007
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Last Update Date | 06/05/2025
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Provider Practice Location Address
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Address Line | 1580 WALDO PALMER LN STE 1A
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City | TALLAHASSEE
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State | FL
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Zip | 32308-6049
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Country | US
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Telephone | 850-942-0096
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Fax |
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Provider Business Mailing Address
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Address Line | 1580 WALDO PALMER LN STE 1A
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City | TALLAHASSEE
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State | FL
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Zip | 32308-6049
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Country | US
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Telephone | 850-942-0096
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | PAUL REYNOLDS
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Credential | DPM
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Telephone | 850-942-0096
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | PO2918
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License Number State | FL
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