1770921819 NPI number — SOUTHERN ORTHOPEDIC & SPORTS MEDICINE ASSOC PC

Table of content: (NPI 1770921819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770921819 NPI number — SOUTHERN ORTHOPEDIC & SPORTS MEDICINE ASSOC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN ORTHOPEDIC & SPORTS MEDICINE ASSOC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770921819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 580
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35502-0580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-221-5374
Provider Business Mailing Address Fax Number:
205-384-1453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35501-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-221-1114
Provider Business Practice Location Address Fax Number:
205-385-0380
Provider Enumeration Date:
06/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PIKE
Authorized Official First Name:
SHERRIE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
205-221-5374

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 529101780 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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