Provider Demographics
NPI:1235396417
Name:SOUTHERN ORTHOPEDIC SPECIALISTS PA
Entity Type:Organization
Organization Name:SOUTHERN ORTHOPEDIC SPECIALISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARREIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-785-4344
Mailing Address - Street 1:1827 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7605
Mailing Address - Country:US
Mailing Address - Phone:850-872-7022
Mailing Address - Fax:850-872-7021
Practice Address - Street 1:1827 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7605
Practice Address - Country:US
Practice Address - Phone:850-872-7022
Practice Address - Fax:850-872-7021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19943225100000X
FLPT19663225100000X
FLOT10791225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY901UOtherBCBS FL