MEDICARE: SOUTHWEST GENERAL MEDICAL GROUP, 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	207V00000X	Obstetrics & Gynecology Physician

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508915364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST GENERAL MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 638269
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-0001
Country	:	US
Telephone Number	:	440-816-4930
Fax Number	:

Provider Business Practice Location Address
First Line	:	18181 PEARL RD
Second Line	:	B206
City	:	STRONGSVILLE
State	:	OH
Zip	:	44136-6949
Country	:	US
Telephone Number	:	440-816-4930
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	HEATHER WAGNER
Credential	:
Telephone Number	:	440-816-4906

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	02/28/2019

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