Healthcare Provider Details

I. General information

NPI: 1689993552
Provider Name (Legal Business Name): SOUTHWEST SPINE AND SPORTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18275 N 59TH AVE SUITE F-132
GLENDALE AZ
85308-1260
US

IV. Provider business mailing address

PO BOX 52001 DEPT 901
PHOENIX AZ
85072-2001
US

V. Phone/Fax

Practice location:
  • Phone: 480-860-8998
  • Fax: 480-377-9245
Mailing address:
  • Phone: 480-860-8998
  • Fax: 480-377-9245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL WARREN WOLFF
Title or Position: PRESIDENT
Credential: M.D.
Phone: 480-860-8998