MEDICARE: SOUTHERN ORTHOPAEDICS AND SPORTS MEDICINE

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	174400000X	Specialist

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427156827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN ORTHOPAEDICS AND SPORTS MEDICINE

Provider Business Mailing Address
First Line	:	1823 N 9TH AVE STE 534
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32503-5270
Country	:	US
Telephone Number	:	850-432-3293
Fax Number	:	850-469-9113

Provider Business Practice Location Address
First Line	:	1823 N 9TH AVE STE 534
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32503-5270
Country	:	US
Telephone Number	:	850-432-3293
Fax Number	:	850-469-9113

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. KELLY A RYSULA
Credential	:
Telephone Number	:	850-432-3293

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	02/24/2020

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Directions to “SOUTHERN ORTHOPAEDICS AND SPORTS MEDICINE ” Practice Location

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