Basic Information
Provider Information
NPI: 1497203194
EntityType: 2
ReplacementNPI:  
OrganizationName: SOUTH WEST INTERNAL MEDICINE LLC
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Mailing Information
Address1: PO BOX 194
Address2:  
City: COQUILLE
State: OR
PostalCode: 974230194
CountryCode: US
TelephoneNumber: 5413290144
FaxNumber: 5413290143
Practice Location
Address1: 913 11TH ST SE STE 1
Address2:  
City: BANDON
State: OR
PostalCode: 974119168
CountryCode: US
TelephoneNumber: 5413290144
FaxNumber: 5413290143
Other Information
ProviderEnumerationDate: 09/12/2016
LastUpdateDate: 11/18/2021
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: CRANE
AuthorizedOfficialFirstName: DOUGLAS
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AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 5413290144
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate: 11/18/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208D00000X  N193400000X MULTIPLE SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansGeneral Practice 
207R00000X  Y193400000X MULTIPLE SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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