Basic Information
| Provider Information | |||||||||
| NPI: | 1962428136 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST UROLOGY, LLC | ||||||||
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| OtherOrganizationName: | SOUTHWEST UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6900 PEARL ROAD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408450900 | ||||||||
| FaxNumber: | 4408457355 | ||||||||
| Practice Location | |||||||||
| Address1: | 6900 PEARL ROAD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408450900 | ||||||||
| FaxNumber: | 4408457355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | BARKOUKIS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4408450900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0634504 | 05 | OH | MEDICAID |