1679663447 NPI number — SOUTHWEST MEDICAL ASSOCIATES, INC

Table of content: (NPI 1679663447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679663447 NPI number — SOUTHWEST MEDICAL ASSOCIATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST MEDICAL ASSOCIATES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHWEST MEDICAL RADIOLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679663447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/04/2019
NPI Reactivation Date:
03/27/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15645
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89114-5645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-560-2874
Provider Business Mailing Address Fax Number:
702-560-2928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
888 S RANCHO DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-877-8600
Provider Business Practice Location Address Fax Number:
702-560-2928
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CASTILLO
Authorized Official First Name:
EMILY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL STAFF MANAGER
Authorized Official Telephone Number:
702-480-2550

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  31797 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002702006 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00112269 . This is a "RR MEDICARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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