Basic Information
| Provider Information | |||||||||
| NPI: | 1093810707 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST HEART GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6567 E CARONDELET DR | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857106152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208863432 | ||||||||
| FaxNumber: | 5208860169 | ||||||||
| Practice Location | |||||||||
| Address1: | 6567 E CARONDELET DR | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857106152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208863432 | ||||||||
| FaxNumber: | 5208860169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 01/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | SLUDER | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OFFFICE SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5208863432 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0147990 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | DG1989 | 01 | AZ | RR MEDICARE | OTHER |