Provider Demographics
NPI:1174960926
Name:ALABAMA ORTHOPAEDIC SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:ALABAMA ORTHOPAEDIC SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-491-2676
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-0478
Mailing Address - Country:US
Mailing Address - Phone:251-491-2676
Mailing Address - Fax:251-491-2685
Practice Address - Street 1:6401 JORDAN RD
Practice Address - Street 2:SUITE A
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4728
Practice Address - Country:US
Practice Address - Phone:251-491-2676
Practice Address - Fax:251-491-2685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21607207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL149441Medicaid
ALDU0298OtherRAILROAD MEDICARE