1467637280 NPI number — SOUTHWEST NEUROLOGY P C

Table of content: (NPI 1467637280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467637280 NPI number — SOUTHWEST NEUROLOGY P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST NEUROLOGY 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:
1467637280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10499
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MOHAVE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86427-0499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-788-4260
Provider Business Mailing Address Fax Number:
928-788-4262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 S HIGHWAY 95
Provider Second Line Business Practice Location Address:
SUITE L
Provider Business Practice Location Address City Name:
FORT MOHAVE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86426-9251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-788-4260
Provider Business Practice Location Address Fax Number:
928-788-4262
Provider Enumeration Date:
12/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
928-788-4260

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  22788 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 215691002 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1415509-3 . This is a "CORPORATION REGISTRATION" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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