Basic Information
| Provider Information | |||||||||
| NPI: | 1396792412 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ORTHOPEDIC ASSOCIATES SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 LINCOLN DRIVE | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189976800 | ||||||||
| FaxNumber: | 6189989124 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 LINCOLN DR | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629486334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189976800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT ORTHOPEDIC SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 6189976800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 261QP1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 332B00000X | 042617215 | KY | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363A00000X | KY | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | 042617215 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.