NPIMap

Organization Active NPI

Southeast Orthopedic Specialists, LLC

  • Specialist
  • Jacksonville, FL
National Provider Identifier
1114383023
Registry record updated Jun 13, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
Legal business name
SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC
Practice address
15255 Max Leggett Pkwy
5TH Floor
Jacksonville, FL 32218-7273
Phone
(904) 634-0640
Fax
(904) 634-0203
NPI assigned
Jan 7, 2016
Last updated
Jun 13, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 13, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Brett PuckettNPI 1831150960
Title
President
Phone
(904) 634-0640

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Specialist 174400000X Primary

Addresses

Primary practice location

15255 Max Leggett Pkwy
5TH Floor
Jacksonville, FL 32218-7273

Mailing address

6500 Bowden Rd
Suite 103
Jacksonville, FL 32216-8070
Phone (904) 634-0640

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160722002500 FL DME Supplier - Physician - Orthopedic/Orthopedic Surgery 1456246974 Practice locations: Jacksonville, FL

Other NPIs with the same Medicare PAC ID 11

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
R David Heekin MD PA38 organizations share this tax ID, including this one

Other organizations with this tax ID 37

Organizations that report the same tax identification number in the National Provider Directory.

View all 37

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1452124800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1686614400000",
    "number": "1114383023",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6500 BOWDEN RD",
            "address_2": "SUITE 103",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322168070",
            "telephone_number": "904-634-0640",
            "fax_number": "904-634-0203"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15255 MAX LEGGETT PKWY",
            "address_2": "5TH FLOOR",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322187273",
            "telephone_number": "904-634-0640",
            "fax_number": "904-634-0203"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-07",
        "last_updated": "2023-06-13",
        "certification_date": "2023-06-13",
        "status": "A",
        "authorized_official_last_name": "PUCKETT",
        "authorized_official_first_name": "BRETT",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "904-634-0640"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.