Basic Information
| Provider Information | |||||||||
| NPI: | 1689993552 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST SPINE AND SPORTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52001 | ||||||||
| Address2: | DEPT 901 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850722001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808608998 | ||||||||
| FaxNumber: | 4803779245 | ||||||||
| Practice Location | |||||||||
| Address1: | 18275 N 59TH AVE | ||||||||
| Address2: | SUITE F-132 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853081260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808608998 | ||||||||
| FaxNumber: | 4803779245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2010 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | WOLFF | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | WARREN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4808608998 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 2081P2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.