Basic Information
| Provider Information | |||||||||
| NPI: | 1265458889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST MEDICAL CONSULTANTS, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 388320 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606388320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737674600 | ||||||||
| FaxNumber: | 7737678320 | ||||||||
| Practice Location | |||||||||
| Address1: | 10458 S PULASKI RD | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604534933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086361818 | ||||||||
| FaxNumber: | 7086362151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | VENKATARAMAN | ||||||||
| AuthorizedOfficialFirstName: | S | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7086361818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST MEDICAL CONSULTANTS, S.C. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 31601474 | 01 | IL | BLUE CROSS | OTHER |