MEDICARE: SOUTHWEST NEUROPHYSIOLOGY, PLLC

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	2084N0600X	Clinical Neurophysiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00LZ77	OTHER	TX	BCBS RECORD ID

General Provider Information

NPI Number	:	1740832120
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST NEUROPHYSIOLOGY, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 3591
Second Line	:
City	:	COPPELL
State	:	TX
Zip	:	75019-5546
Country	:	US
Telephone Number	:	469-343-5984
Fax Number	:	888-516-0585

Provider Business Practice Location Address
First Line	:	2452 LAKEWOOD DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-6800
Country	:	US
Telephone Number	:	469-343-5989
Fax Number	:	888-516-0585

Authorized Official
Title or Position	:	OWNER
Name	:	UYENLY NGUYEN
Credential	:	CNIM R. EPT., R CNST
Telephone Number	:	469-343-5989

Provider Enumeration Date	:	07/15/2019
Last Update Date	:	02/18/2021

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