MEDICARE: HUGHSTON CLINIC SOUTHEAST PC

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	332B00000X	Durable Medical Equipment & Medical Supplies		FL

General Provider Information

NPI Number	:	1134605223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUGHSTON CLINIC SOUTHEAST PC

Provider Business Mailing Address
First Line	:	6262 VETERANS PKWY
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31909-3540
Country	:	US
Telephone Number	:	706-494-3071
Fax Number	:	706-494-3008

Provider Business Practice Location Address
First Line	:	3627 UNIVERSITY BLVD S STE 550
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-7401
Country	:	US
Telephone Number	:	904-570-8604
Fax Number	:	904-458-4819

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	AMANDA GRACE FROMKIN
Credential	:
Telephone Number	:	706-494-3071

Provider Enumeration Date	:	07/12/2018
Last Update Date	:	08/18/2023

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