Healthcare Provider Details

I. General information

NPI: 1427165554
Provider Name (Legal Business Name): SOUTHERN ORTHOPEDIC ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4787 ALBEN BARKLEY DRIVE
PADUCAH KY
42002
US

IV. Provider business mailing address

510 LINCOLN DRIVE
HERRIN IL
62948
US

V. Phone/Fax

Practice location:
  • Phone: 270-442-9461
  • Fax: 270-441-0079
Mailing address:
  • Phone: 618-997-6800
  • Fax: 618-998-9635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 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 Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number042617215
License Number StateIL

VIII. Authorized Official

Name: JAMES MICHAEL DAVIS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 618-997-6800