Provider Demographics
NPI: | 1497371405 |
---|---|
Name: | SOUTHLAKE ORTHOPAEDICS SPORTS MEDICINE AND SPINE CENTER, PC |
Entity Type: | Organization |
Organization Name: | SOUTHLAKE ORTHOPAEDICS SPORTS MEDICINE AND SPINE CENTER, PC |
Other - Org Name: | SOUTHLAKE ORTHOPAEDICS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | JEREMY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SCHRIMSHER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 205-985-4111 |
Mailing Address - Street 1: | 4517 SOUTHLAKE PKWY |
Mailing Address - Street 2: | |
Mailing Address - City: | HOOVER |
Mailing Address - State: | AL |
Mailing Address - Zip Code: | 35244-3280 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 205-985-4111 |
Mailing Address - Fax: | 205-985-4326 |
Practice Address - Street 1: | 4517 SOUTHLAKE PKWY |
Practice Address - Street 2: | |
Practice Address - City: | HOOVER |
Practice Address - State: | AL |
Practice Address - Zip Code: | 35244-3280 |
Practice Address - Country: | US |
Practice Address - Phone: | 205-985-4111 |
Practice Address - Fax: | 205-985-4326 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-06-25 |
Last Update Date: | 2023-03-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207XS0117X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | Group - Multi-Specialty |
No | 207XX0004X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | Group - Multi-Specialty |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 222Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotist | Group - Multi-Specialty | |
No | 224P00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Prosthetist | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 2471C3402X | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography | Group - Multi-Specialty |
No | 2471M1202X | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Magnetic Resonance Imaging | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 207RS0010X | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | Group - Multi-Specialty |