MEDICARE: SOUTH COUNTY ORTHOPEDICS AND SPORTS MEDICINE INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

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

General Provider Information

NPI Number	:	1164692729
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH COUNTY ORTHOPEDICS AND SPORTS MEDICINE INC

Provider Business Mailing Address
First Line	:	10004 KENNERLY RD STE 274B
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2177
Country	:	US
Telephone Number	:	314-849-7979
Fax Number	:	314-849-3555

Provider Business Practice Location Address
First Line	:	10004 KENNERLY RD STE 274B
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2177
Country	:	US
Telephone Number	:	314-849-7979
Fax Number	:	314-849-3555

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL HAROLD RALPH
Credential	:	M.D.
Telephone Number	:	314-849-7979

Provider Enumeration Date	:	03/10/2008
Last Update Date	:	01/07/2009

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