Healthcare Provider Details

I. General information

NPI: 1396792412
Provider Name (Legal Business Name): SOUTHERN ORTHOPEDIC ASSOCIATES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 LINCOLN DR
HERRIN IL
62948-6334
US

IV. Provider business mailing address

510 LINCOLN DRIVE
HERRIN IL
62948
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-6800
  • Fax:
Mailing address:
  • Phone: 618-997-6800
  • Fax: 618-998-9124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number042617215
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number042617215
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKY

VIII. Authorized Official

Name: DR. JOHN DAVIS
Title or Position: PRESIDENT ORTHOPEDIC SURGEON
Credential: MD
Phone: 618-997-6800