1821247495 NPI number — SOUTHWEST GASTROENTEROLOGY, S.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821247495 NPI number — SOUTHWEST GASTROENTEROLOGY, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST GASTROENTEROLOGY, S.C.
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:
Provider Other Organization Name Type Code:
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:
1821247495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9921 SOUTHWEST HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK LAWN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60453-3767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-499-5678
Provider Business Mailing Address Fax Number:
708-499-5685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9921 SOUTHWEST HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK LAWN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60453-3767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-499-5678
Provider Business Practice Location Address Fax Number:
708-499-5685
Provider Enumeration Date:
09/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PORT
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-499-5678

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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