Provider Demographics
NPI:1508447343
Name:SOUTHLAKE ORTHOPAEDICS DBA SOUTHLAKE PROSTHETICS & ORTHOTICS
Entity Type:Organization
Organization Name:SOUTHLAKE ORTHOPAEDICS DBA SOUTHLAKE PROSTHETICS & ORTHOTICS
Other - Org Name:SOUTHLAKE ORTHOPAEDICS DBA SOUTHLAKE PROSTHETICS & ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CRABTREE
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:205-267-4411
Practice Address - Street 1:4524 SOUTHLAKE PKWY STE 26
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3272
Practice Address - Country:US
Practice Address - Phone:205-985-4111
Practice Address - Fax:205-267-4411
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHLAKE ORTHOPAEDICS SPORTS MEDICINE & SPINE CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-14
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL124555Medicaid