Provider Demographics
NPI:1952311631
Name:SOUTH ALABAMA ORTHOPEDICS & SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:SOUTH ALABAMA ORTHOPEDICS & SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-445-2663
Mailing Address - Street 1:PO BOX 1025
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36361-1025
Mailing Address - Country:US
Mailing Address - Phone:334-445-2663
Mailing Address - Fax:
Practice Address - Street 1:2126 W ROY PARKER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-8566
Practice Address - Country:US
Practice Address - Phone:334-445-2663
Practice Address - Fax:334-774-7271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-563207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1952311631Medicaid
ALI57556Medicare UPIN
AL1952311631Medicaid