Healthcare Provider Details

I. General information

NPI: 1053568428
Provider Name (Legal Business Name): SOUTHERN ORTHOPEDICS AND SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 LEONARD FULGHUM BLVD SUITE 101
MT PLEASANT SC
29464-3787
US

IV. Provider business mailing address

851 LEONARD FULGHUM BLVD SUITE 101
MT PLEASANT SC
29464-3787
US

V. Phone/Fax

Practice location:
  • Phone: 843-971-9350
  • Fax: 843-971-9351
Mailing address:
  • Phone: 843-971-9350
  • Fax: 843-971-9351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL KYLE BURTNETT
Title or Position: SVP OF OUTPATIENT SERVICES, TENET
Credential:
Phone: 469-893-2153