Basic Information
| Provider Information | |||||||||
| NPI: | 1033448576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST SPORTS AND SPINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70232 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857370030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203950512 | ||||||||
| FaxNumber: | 5205054108 | ||||||||
| Practice Location | |||||||||
| Address1: | 5860 N LA CHOLLA BLVD STE 150 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857413562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203950512 | ||||||||
| FaxNumber: | 5205054108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2009 | ||||||||
| LastUpdateDate: | 07/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5203950512 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | AZ | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 498019 | 05 | AZ | MEDICAID |