Healthcare Provider Details

I. General information

NPI: 1538289152
Provider Name (Legal Business Name): SOUTHWEST VASCULAR INSTITUTE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD G 116
GLENDALE AZ
85306-3709
US

IV. Provider business mailing address

6677 W THUNDERBIRD RD G 116
GLENDALE AZ
85306-3709
US

V. Phone/Fax

Practice location:
  • Phone: 623-435-1954
  • Fax: 623-435-1955
Mailing address:
  • Phone: 623-435-1954
  • Fax: 623-435-1955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number22494
License Number StateAZ

VIII. Authorized Official

Name: CECIL C VAUGHN III
Title or Position: PRESIDENT OWNER
Credential: M.D.
Phone: 623-435-1954