Provider Demographics
NPI:1154412419
Name:SOUTHPORT ORTHOPEDICS AND SPORTS MEDICINE
Entity type:Organization
Organization Name:SOUTHPORT ORTHOPEDICS AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:AUVIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-803-8200
Mailing Address - Street 1:3 HANDLEY ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:NY
Mailing Address - Zip Code:14530-1342
Mailing Address - Country:US
Mailing Address - Phone:585-237-2980
Mailing Address - Fax:585-237-5570
Practice Address - Street 1:3 HANDLEY ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:NY
Practice Address - Zip Code:14530-1342
Practice Address - Country:US
Practice Address - Phone:585-237-2980
Practice Address - Fax:585-237-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY270031Medicare ID - Type Unspecified