MEDICARE: SOUTHWEST VASCULAR P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician
2	2086S0129X	Vascular Surgery Physician

General Provider Information

NPI Number	:	1093273781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST VASCULAR P.C.

Provider Business Mailing Address
First Line	:	2737 SOUTH HULEN STREET
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109
Country	:	US
Telephone Number	:	817-770-0608
Fax Number	:

Provider Business Practice Location Address
First Line	:	4375 BOOTH CALLAWAY SUITE 501
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76180
Country	:	US
Telephone Number	:	817-770-0608
Fax Number	:

Authorized Official
Title or Position	:	ADMISTRATOR
Name	:	MARTHA PROVIDENZA
Credential	:
Telephone Number	:	817-614-9552

Provider Enumeration Date	:	03/12/2019
Last Update Date	:	03/12/2019

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