Basic Information
| Provider Information | |||||||||
| NPI: | 1518022144 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWESTERN MEDICAL CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8008 M-139 | ||||||||
| Address2: | |||||||||
| City: | BERRIEN SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694711700 | ||||||||
| FaxNumber: | 2694711975 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491204074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696870200 | ||||||||
| FaxNumber: | 2696840199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 05/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2694711700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.