Provider Demographics
NPI:1639746050
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:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EKKEHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BONATZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:
Practice Address - Street 1:7191 CAHABA VALLEY RD
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35242-6443
Practice Address - Country:US
Practice Address - Phone:205-985-4111
Practice Address - Fax:205-267-4411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-04
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529802230Medicaid