Basic Information
Provider Information | |||||||||
NPI: | 1700110988 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHWESTERN MEDICAL CENTERS INC - AZ | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THUMB BUTTE OUTPATIENT REHAB CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020 NE LOOP 410 | ||||||||
Address2: | SUITE 640 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782091204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2108285686 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 864 DOUGHERTY ST | ||||||||
Address2: |   | ||||||||
City: | PRESCOTT | ||||||||
State: | AZ | ||||||||
PostalCode: | 863051841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287789666 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2009 | ||||||||
LastUpdateDate: | 09/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUDSON | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | WESLEY | ||||||||
AuthorizedOfficialTitleorPosition: | V.P. OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 2108285686 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | OTC 4666 | AZ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.