MEDICARE: SOUTHWEST IMAGING CENTER INC

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	2085R0202X	Diagnostic Radiology Physician	700560	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285637017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST IMAGING CENTER INC

Provider Business Mailing Address
First Line	:	5116 W GORE BLVD
Second Line	:	STE 1
City	:	LAWTON
State	:	OK
Zip	:	73505-5909
Country	:	US
Telephone Number	:	580-353-7226
Fax Number	:	580-353-7297

Provider Business Practice Location Address
First Line	:	5116 W GORE BLVD
Second Line	:	STE 1
City	:	LAWTON
State	:	OK
Zip	:	73505-5909
Country	:	US
Telephone Number	:	580-353-7226
Fax Number	:	580-353-7297

Authorized Official
Title or Position	:	BILLING OFFICE MANAGAER
Name	:	MRS. KIMBERLY LYNN KETCHER
Credential	:
Telephone Number	:	580-353-7226

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	08/20/2008

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