1902176597 NPI number — SOUTHWEST SPINE CENTER PLLC

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 1902176597 NPI number — SOUTHWEST SPINE CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST SPINE CENTER PLLC
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:
1902176597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26421 SOUTHFIELD ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LATHRUP VILLAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
249-805-5066
Provider Business Mailing Address Fax Number:
249-905-5069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
521 N BURR OAK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49040-9403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-432-9595
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AWWAD
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
VICTOR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-432-9595

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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