Provider Demographics
NPI:1013965789
Name:SOUTHERN ORTHOPAEDIC SPORTS MEDICNE
Entity Type:Organization
Organization Name:SOUTHERN ORTHOPAEDIC SPORTS MEDICNE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:EKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-376-8880
Mailing Address - Street 1:1718 SAINT JULIAN PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2410
Mailing Address - Country:US
Mailing Address - Phone:803-376-8880
Mailing Address - Fax:803-376-8881
Practice Address - Street 1:1718 SAINT JULIAN PL
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2410
Practice Address - Country:US
Practice Address - Phone:803-376-8880
Practice Address - Fax:803-376-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19175207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2755Medicaid
SC6713Medicare PIN