| Organization Name: | SE ORTHOPEDIC SPECIALISTS |
| NPI Number: | 1669837076 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | NICOLE SISKO (CREDENTIALING SPECIALIST) |
| Mailing Address: | 232 Ponte Vedra Park Dr Ponte Vedra |
| State: | FL US |
| Postal Code: | 320826600 |
| Phone Number: | 7277550693 |
| Fax Number: | 7277550679 |
| NPI Enumeration Date: | 12/30/2015 |
| NPI Last Update Date: | 12/30/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332900000X |
| License Number: | ME80485 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Non-Pharmacy Dispensing Site |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.) |