Southlake Orthopaedics Sports Medicine & Spine Center, Inc.

Contacts

Phone	+1 205-985-4111
Fax	2052674411

Authorized person

Name	DR. EKKEHARD BONATZ
Role	PHYSICIAN
Phone	2059854111

Taxonomy

Taxonomy Code	207XS0106X - Orthopaedic Hand Surgery Physician
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	529802230
State	AL

File	View Page
Three-digit plan number (PN)	502
Effective date of plan	2023-05-01
Business code	621399
Sponsor’s telephone number	2053297552
Plan sponsor’s DBA name	SOUTHLAKE ORTHOPAEDICS
Plan sponsor’s mailing address	4517 SOUTHLAKE PKWY, HOOVER, AL, 352443238
Plan sponsor’s address	4517 SOUTHLAKE PKWY, HOOVER, AL, 352443238

Number of participants as of the end of the plan year

Active participants	0
Retired or separated participants receiving benefits	0
Other retired or separated participants entitled to future benefits	0
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits	0

Signature of

Role	Plan administrator
Date	2024-06-28
Name of individual signing	MICHELE RYGIEL
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2024-06-28
Name of individual signing	MICHELE RYGIEL
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	501
Effective date of plan	2023-05-01
Business code	621399
Sponsor’s telephone number	2053297552
Plan sponsor’s DBA name	SOUTHLAKE ORTHOPAEDICS
Plan sponsor’s mailing address	4517 SOUTHLAKE PKWY, HOOVER, AL, 352443238
Plan sponsor’s address	4517 SOUTHLAKE PKWY, HOOVER, AL, 352443238

Number of participants as of the end of the plan year

Active participants	0
Retired or separated participants receiving benefits	0
Other retired or separated participants entitled to future benefits	0
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits	0

Signature of

Role	Plan administrator
Date	2024-06-28
Name of individual signing	MICHELE RYGIEL
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2024-06-28
Name of individual signing	MICHELE RYGIEL
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2059854111
Plan sponsor’s address	4517 SOUTHLAKE PARKWAY, STE 202, BIRMINGHAM, AL, 352443281

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2059854111
Plan sponsor’s address	4517 SOUTHLAKE PARKWAY, STE 202, BIRMINGHAM, AL, 352443281

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2059854111
Plan sponsor’s address	4517 SOUTHLAKE PARKWAY, STE 202, BIRMINGHAM, AL, 352443281

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2059854111
Plan sponsor’s address	4517 SOUTHLAKE PARKWAY, STE 202, BIRMINGHAM, AL, 352443281

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2059854111
Plan sponsor’s address	4517 SOUTHLAKE PARWKAY, STE 202, BIRMINGHAM, AL, 35244

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2059854111
Plan sponsor’s address	4517 SOUTHLAKE PARWKAY, STE 202, BIRMINGHAM, AL, 35244

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2059854111
Plan sponsor’s address	4517 SOUTHLAKE PARWKAY, STE 202, BIRMINGHAM, AL, 35244

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2059854111
Plan sponsor’s address	4517 SOUTHLAKE PARWKAY, STE 202, BIRMINGHAM, AL, 35244

Signature of

Role	Plan administrator
Date	2013-03-27
Name of individual signing	BARRY GALLO