Basic Information
| Provider Information | |||||||||
| NPI: | 1821083387 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SWIFTS CRITICAL CARE NETWORK FOR CHILDREN MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3006 S MARYLAND PKWY | ||||||||
| Address2: | #505 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891092218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883502911 | ||||||||
| FaxNumber: | 7023695827 | ||||||||
| Practice Location | |||||||||
| Address1: | 18321 CLARK ST | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913563501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883502911 | ||||||||
| FaxNumber: | 7023695827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SWIFT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8883502911 | ||||||||
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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 | 2080P0203X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0084493 | 05 | CA | MEDICAID |