Healthcare Provider Details

I. General information

NPI: 1457517104
Provider Name (Legal Business Name): SOUTHWEST MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 W FLAMINGO RD
LAS VEGAS NV
89103-2201
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-876-4449
  • Fax: 702-252-4906
Mailing address:
  • Phone: 702-560-2879
  • Fax: 702-560-2928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number13063
License Number StateNV

VIII. Authorized Official

Name: DR. LINDA JOHNSON
Title or Position: PRESIDENT
Credential: MD
Phone: 702-877-8600