Provider Demographics
NPI:1184647323
Name:SOUTHERN ORTHOPEDIC & SPORTS MEDICINE ASSOC P C
Entity Type:Organization
Organization Name:SOUTHERN ORTHOPEDIC & SPORTS MEDICINE ASSOC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:PIKE
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:205-221-5374
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35502-0580
Mailing Address - Country:US
Mailing Address - Phone:205-221-5374
Mailing Address - Fax:205-384-1453
Practice Address - Street 1:2950 HIGHWAY 78 E
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8903
Practice Address - Country:US
Practice Address - Phone:205-221-5374
Practice Address - Fax:205-384-1453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529101780Medicaid
AL0353430002Medicare NSC