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	:	1598286684
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	:	341 RACETRACK RD NW STE C
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1552
Country	:	US
Telephone Number	:	850-226-8112
Fax Number	:	850-362-6068

Authorized Official
Title or Position	:	CRED COORD
Name	:	AMANDA FROMKIN
Credential	:
Telephone Number	:	706-494-3071

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	08/18/2023

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