Basic Information
| Provider Information | |||||||||
| NPI: | 1164755179 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST HEALTHCARE OF BROWN COUNTY OHIO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHWEST REGIONAL MEDICAL CENTER - BETHEL RURAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 N UNION ST | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451061124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137349050 | ||||||||
| FaxNumber: | 5137349051 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 N UNION ST | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451061124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137349050 | ||||||||
| FaxNumber: | 5137349051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | SURAPANENI | ||||||||
| AuthorizedOfficialFirstName: | KRISHNA | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9373787800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST HEALTHCARE OF BROWN COUNTY OHIO, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 1115 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1902940042 | 01 | OH | NPI | OTHER |