Provider Demographics
NPI:1053568428
Name:SOUTHERN ORTHOPEDICS AND SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:SOUTHERN ORTHOPEDICS AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP OF OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2153
Mailing Address - Street 1:851 LEONARD FULGHUM BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3787
Mailing Address - Country:US
Mailing Address - Phone:843-971-9350
Mailing Address - Fax:843-971-9351
Practice Address - Street 1:851 LEONARD FULGHUM BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3787
Practice Address - Country:US
Practice Address - Phone:843-971-9350
Practice Address - Fax:843-971-9351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5001Medicaid
SC9148Medicare PIN
SCD05148Medicare PIN