Basic Information
| Provider Information | |||||||||
| NPI: | 1225021819 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN ORTHOPEDIC ASSOCIATES, S.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORTHOPEDIC INSTITUTE OF WESTERN KENTUCKY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 LINCOLN DR | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629486334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189976800 | ||||||||
| FaxNumber: | 6189989124 | ||||||||
| Practice Location | |||||||||
| Address1: | 3530 LONE OAK RD | ||||||||
| Address2: | STE A | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420035752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705540505 | ||||||||
| FaxNumber: | 2705540905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 01/10/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6189976800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 042617215 | IL | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | 36333 | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100080520 | 05 | KY | MEDICAID |