Healthcare Provider Details

I. General information

NPI: 1689819898
Provider Name (Legal Business Name): SOUTHWEST MEDICAL CENTER SURGICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 W CONGRESS ST SUITE 3200
LAFAYETTE LA
70506-6765
US

IV. Provider business mailing address

4212 W CONGRESS ST SUITE 2300A
LAFAYETTE LA
70506-6765
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-1695
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: MR. MATTHEW SHANE OLIVIER
Title or Position: AUTHORIZED OFFICAL
Credential:
Phone: 615-373-7600