Basic Information
| Provider Information | |||||||||
| NPI: | 1104075126 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ORTHOPEDIC ASSOCIATES, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 LINCOLN DRIVE | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189976800 | ||||||||
| FaxNumber: | 6184570211 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 DIANN LANE | ||||||||
| Address2: | |||||||||
| City: | CARRONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189976800 | ||||||||
| FaxNumber: | 6184570211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 09/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | WEST | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/ORTHOPEDIC SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 6189976800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 042617215 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.