MEDICARE: SOUTHEAST OUTPATIENT CONSULTANTS LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1023450012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST OUTPATIENT CONSULTANTS LLC

Provider Business Mailing Address
First Line	:	1665 KINGSLEY AVE
Second Line	:	SUITE 105
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4490
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1465 KINGSLEY AVE
Second Line	:	1201
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4504
Country	:	US
Telephone Number	:	904-421-2119
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED AGENT
Name	:	DEEVID MILLER
Credential	:
Telephone Number	:	904-421-2119

Provider Enumeration Date	:	07/19/2013
Last Update Date	:	07/19/2013

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