Basic Information
| Provider Information | |||||||||
| NPI: | 1104122621 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST NEUROLOGY AND SLEEP MEDICINE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLUESKY FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W GLENDALE AVE STE 203 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850217677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027725770 | ||||||||
| FaxNumber: | 6027725771 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 W GLENDALE AVE STE 203 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850217677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027725770 | ||||||||
| FaxNumber: | 6027725771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 04/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | DOORANI | ||||||||
| AuthorizedOfficialFirstName: | SUMAIRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6027725770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST NEUROLOGY AND SLEEP MEDICINE LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QS1201X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine | 2084N0400X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | Z143146 | 01 | AZ | PTAN | OTHER | 8293938 | 05 | WA | MEDICAID |