NPIMap

Organization Active NPI

Southeast Orthopedic Specialists, LLC

  • Orthopaedic Surgery Physician
  • Jacksonville, FL
National Provider Identifier
1295156941
Registry record updated Dec 12, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthopaedic Surgery PhysicianTaxonomy code 207X00000X
Legal business name
SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC
Practice address
10475 Centurion Pkwy N Ste 220
Jacksonville, FL 32256-5004
Phone
(904) 634-0640
Fax
(904) 674-6155
NPI assigned
Dec 26, 2013
Last updated
Dec 12, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 12, 2022

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

Authorized official

Name
Brett N Puckett
Title
Physician/Authorized
Phone
(904) 349-0290

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Specialist 174400000X
Orthopaedic Surgery Physician 207X00000X Primary

Addresses

Primary practice location

10475 Centurion Pkwy N Ste 220
Jacksonville, FL 32256-5004

Mailing address

6800 Southpoint Pkwy Ste 300
Jacksonville, FL 32216-8203
Phone (904) 634-0640

Other identifiers 1

IdentifierTypeStateIssuer
74895OtherFLBCBS

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130816000864 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

Locations

10475 Centurion Pkwy N
Ste 102
Jacksonville, FL 32256

Practitioners & affiliated clinicians

Practitioners 1

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": "1388016000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1670803200000",
    "number": "1295156941",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6800 SOUTHPOINT PKWY STE 300",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322168203",
            "telephone_number": "904-634-0640",
            "fax_number": "904-674-6155"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10475 CENTURION PKWY N STE 220",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322565004",
            "telephone_number": "904-634-0640",
            "fax_number": "904-674-6155"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-26",
        "last_updated": "2022-12-12",
        "certification_date": "2022-12-12",
        "status": "A",
        "authorized_official_last_name": "PUCKETT",
        "authorized_official_first_name": "BRETT",
        "authorized_official_middle_name": "N",
        "authorized_official_title_or_position": "PHYSICIAN/AUTHORIZED",
        "authorized_official_telephone_number": "904-349-0290"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "74895",
            "state": "FL"
        }
    ],
    "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 Dec 12, 2022; 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.