Provider Demographics
NPI:1427156827
Name:SOUTHERN ORTHOPAEDICS AND SPORTS MEDICINE
Entity type:Organization
Organization Name:SOUTHERN ORTHOPAEDICS AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RYSULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-432-3293
Mailing Address - Street 1:1823 N 9TH AVE STE 534
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-5270
Mailing Address - Country:US
Mailing Address - Phone:850-432-3293
Mailing Address - Fax:850-469-9113
Practice Address - Street 1:1823 N 9TH AVE STE 534
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-5270
Practice Address - Country:US
Practice Address - Phone:850-432-3293
Practice Address - Fax:850-469-9113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529200280Medicaid
FL263501100Medicaid
FLCI2893Medicare PIN
ALI708Medicare PIN
FL0650100001Medicare NSC
FL98645Medicare PIN