Basic Information
| Provider Information | |||||||||
| NPI: | 1164439774 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN SPORTS MEDICINE AND ORTHOPAEDIC CENTER, P.C. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHERN JOINT REPLACEMENT INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4230 HARDING RD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153420038 | ||||||||
| FaxNumber: | 6153294469 | ||||||||
| Practice Location | |||||||||
| Address1: | 4230 HARDING RD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153420038 | ||||||||
| FaxNumber: | 6153294469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 06/27/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 6153241723 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.