Healthcare Provider Details

I. General information

NPI: 1811027808
Provider Name (Legal Business Name): SOUTHWEST MEDICAL SPECIALISTS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6311 W 95TH STREET
OAK LAWN IL
60453-2201
US

IV. Provider business mailing address

6311 W 95TH STREET
OAK LAWN IL
60453-2201
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-2258
  • Fax: 708-423-2305
Mailing address:
  • Phone: 708-423-2258
  • Fax: 708-423-2305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number042006686
License Number StateIL

VIII. Authorized Official

Name: MRS. KARYN MELICHAR
Title or Position: BILLING MANAGER
Credential:
Phone: 708-423-2258