Basic Information
| Provider Information | |||||||||
| NPI: | 1841776937 | ||||||||
| 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: | 2202 STATE AVE STE 303 | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324054590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507672455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2018 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | FROMKIN | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | GRACE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CREDENTIALING | ||||||||
| 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.