=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023647476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST SURGICAL ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2020
-----------------------------------------------------
Last Update Date | 04/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 1ST ST NW STE 2
-----------------------------------------------------
City | PULASKI
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24301-5605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-577-4882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8229 RIVER COURSE DR
-----------------------------------------------------
City | RADFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24141-6912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-577-4882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STUART HAL GOLDSTEIN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 540-577-4882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------