1104031996 NPI number — SOUTHWESTERN MEDICAL ASSOCIATES, P.C.

Table of content: (NPI 1104031996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104031996 NPI number — SOUTHWESTERN MEDICAL ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWESTERN MEDICAL ASSOCIATES, P.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:
1104031996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 NW 40TH ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73505-3656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-353-5030
Provider Business Mailing Address Fax Number:
580-353-5045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 NW 40TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505-3656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-353-5030
Provider Business Practice Location Address Fax Number:
580-353-5045
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOVE
Authorized Official First Name:
VERNON
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
580-353-5030

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  24537 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: K8651 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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