=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770610636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN ORTHOPAEDICS & SPORTS MEDICINE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 07/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5009 S MCCOLL ROAD
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-213-8881
-----------------------------------------------------
Fax | 956-213-8886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5009 S MCCOLL ROAD
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-213-8881
-----------------------------------------------------
Fax | 956-213-8886
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. FRED LAUREL PEREZ JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 956-213-8881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XP3100X
-----------------------------------------------------
Taxonomy Name | Pediatric Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | F8611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XS0106X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Hand Surgery Physician
-----------------------------------------------------
License Number | F8611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | F8611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | F8611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207XX0004X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Foot and Ankle Surgery Physician
-----------------------------------------------------
License Number | F8611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | F8611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207XX0801X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Trauma Physician
-----------------------------------------------------
License Number | F8611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | F8611
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------