Provider Demographics
NPI:1760790257
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:JAMES
Authorized Official - Middle Name:MICHAEL
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 1:4787 ALBEN BARKLEY DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-6789
Practice Address - Country:US
Practice Address - Phone:270-442-9461
Practice Address - Fax:270-441-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.617215207X00000X
IL042617215332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4216620002OtherMEDICARE DME