Basic Information
| Provider Information | |||||||||
| NPI: | 1376587733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST CARDIOLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3533 SOUTHERN BLVD | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372933486 | ||||||||
| FaxNumber: | 9372933605 | ||||||||
| Practice Location | |||||||||
| Address1: | 8057 WASHINGTON VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454581847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373129890 | ||||||||
| FaxNumber: | 9372933605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 02/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | STULTZ | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372933486 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 060053779 | 01 | OH | RR MEDICARE | OTHER | 1540749 | 01 | OH | THE FUNDS UMW | OTHER | 2375700 | 05 | OH | MEDICAID | 020191600 | 01 | OH | BLACK LUNG PROGRAM | OTHER |