Healthcare Provider Details

I. General information

NPI: 1740598390
Provider Name (Legal Business Name): SOUTHERN ORTHOPEDIC ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 LONE OAK RD SUITE A
PADUCAH KY
42003-5752
US

IV. Provider business mailing address

510 LINCOLN DR
HERRIN IL
62948-6334
US

V. Phone/Fax

Practice location:
  • Phone: 270-554-0505
  • Fax: 270-554-0905
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 Number042.617215
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number042617215
License Number StateIL

VIII. Authorized Official

Name: DR. THOMAS WEST DAVIS
Title or Position: PRESIDENT
Credential:
Phone: 618-997-6800