Provider Demographics
NPI:1396792412
Name:SOUTHERN ORTHOPEDIC ASSOCIATES SC
Entity type:Organization
Organization Name:SOUTHERN ORTHOPEDIC ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT ORTHOPEDIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-997-6800
Mailing Address - Street 1:510 LINCOLN DRIVE
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948
Mailing Address - Country:US
Mailing Address - Phone:618-997-6800
Mailing Address - Fax:618-998-9124
Practice Address - Street 1:510 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-997-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 261QP1100X
KY042617215332B00000X
KY363A00000X
IL042617215207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL591820Medicare ID - Type Unspecified
IL4216620001Medicare NSC