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General NPI Number Information
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NPI Number | 1104075126
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Entity Type | Organization
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Legal Business Name | SOUTHERN ORTHOPEDIC ASSOCIATES, S.C.
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Dates
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Enumeration Date | 09/15/2008
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Last Update Date | 09/15/2008
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Provider Practice Location Address
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Address Line | 1101 DIANN LANE
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City | CARRONDALE
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State | IL
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Zip | 62901
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Country | US
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Telephone | 618-997-6800
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Fax | 618-457-0211
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Provider Business Mailing Address
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Address Line | 510 LINCOLN DRIVE
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City | HERRIN
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State | IL
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Zip | 62948
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Country | US
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Telephone | 618-997-6800
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Fax | 618-457-0211
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Authorized Official
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Title or Position | PRESIDENT/ORTHOPEDIC SURGEON
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Name | DR. THOMAS WEST DAVIS
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Credential |
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Telephone | 618-997-6800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 042617215
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License Number State | IL
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