Healthcare Provider Details

I. General information

NPI: 1205985967
Provider Name (Legal Business Name): SOUTHWEST GENERAL MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18780 BAGLEY RD # 100
CLEVELAND OH
44130-3304
US

IV. Provider business mailing address

PO BOX 638269
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 440-816-2850
  • Fax:
Mailing address:
  • Phone: 440-816-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER WAGNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 440-816-4906