MEDICARE: SOUTHLAKE ORTHOPAEDICS SPORTS MEDICINE & SPINE CENTER PC

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician
2	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician
3	174400000X	Specialist	9307	AL
4	207XS0106X	Orthopaedic Hand Surgery Physician
5	207XS0117X	Orthopaedic Surgery of the Spine Physician
6	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician
7	222Z00000X	Orthotist
8	224L00000X	Pedorthist
9	224P00000X	Prosthetist
10	225000000X	Orthotic Fitter
11	225100000X	Physical Therapist
12	225X00000X	Occupational Therapist
13	2471M1202X	Magnetic Resonance Imaging Radiologic Technologist
14	363A00000X	Physician Assistant
15	207X00000X	Orthopaedic Surgery Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G715	OTHER	AL	MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1043268402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHLAKE ORTHOPAEDICS SPORTS MEDICINE & SPINE CENTER PC

Provider Business Mailing Address
First Line	:	4517 SOUTHLAKE PKWY
Second Line	:
City	:	HOOVER
State	:	AL
Zip	:	35244-3280
Country	:	US
Telephone Number	:	205-985-4111
Fax Number	:	205-985-4326

Provider Business Practice Location Address
First Line	:	4517 SOUTHLAKE PKWY
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35244-3280
Country	:	US
Telephone Number	:	205-985-4111
Fax Number	:	205-985-4326

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL FRANCES BLUM
Credential	:
Telephone Number	:	205-985-4111

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	02/10/2022