MEDICARE: SOUTHWEST SURGICAL ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	808232	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7332427	OTHER	TX	AETNA HEALTHCARE
2	2285573	OTHER	UT	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1073873519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST SURGICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	PO BOX 101292
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76185-1292
Country	:	US
Telephone Number	:	817-808-8467
Fax Number	:	817-921-3352

Provider Business Practice Location Address
First Line	:	4216 SW LOOP 820
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5350
Country	:	US
Telephone Number	:	817-808-8467
Fax Number	:	817-921-3352

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. CHRISTOPHER R LYNCH
Credential	:	CST/CSFA/RN
Telephone Number	:	817-808-8467

Provider Enumeration Date	:	05/17/2012
Last Update Date	:	05/17/2012

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