Provider Demographics
NPI:1225021819
Name:SOUTHERN ORTHOPEDIC ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:SOUTHERN ORTHOPEDIC ASSOCIATES, S.C.
Other - Org Name:ORTHOPEDIC INSTITUTE OF WESTERN KENTUCKY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-997-6800
Mailing Address - Street 1:510 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-6334
Mailing Address - Country:US
Mailing Address - Phone:618-997-6800
Mailing Address - Fax:618-998-9124
Practice Address - Street 1:3530 LONE OAK RD
Practice Address - Street 2:STE A
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-5752
Practice Address - Country:US
Practice Address - Phone:270-554-0505
Practice Address - Fax:270-554-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36333207X00000X
IL042617215332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100080520Medicaid
KY00973Medicare PIN
KY7100080520Medicaid