Basic Information
| Provider Information | |||||||||
| NPI: | 1235414905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST WOUND CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 W 32ND ST | ||||||||
| Address2: | # 547 | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853648128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192586200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 W 24TH ST | ||||||||
| Address2: | #205 | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853646370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283442000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2011 | ||||||||
| LastUpdateDate: | 10/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | DICKSON | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6192586200 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST EMERGENCY PHYSICIANS, P.L.L.C. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0005X | 4064 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine |
No ID Information.