Basic Information
| Provider Information | |||||||||
| NPI: | 1598286684 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUGHSTON CLINIC SOUTHEAST PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6262 VETERANS PKWY | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319093540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064943071 | ||||||||
| FaxNumber: | 7064943008 | ||||||||
| Practice Location | |||||||||
| Address1: | 341 RACETRACK RD NW STE C | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325471552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502268112 | ||||||||
| FaxNumber: | 8503626068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | FROMKIN | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CRED COORD | ||||||||
| AuthorizedOfficialTelephone: | 7064943071 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | FL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.