MEDICARE: SOUTHWEST MEDICAL ASSOCIATES, LLC

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	207Q00000X	Family Medicine Physician
2	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1578255253
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST MEDICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	340 SEVEN SPRINGS WAY STE 100
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-5697
Country	:	US
Telephone Number	:	615-296-3594
Fax Number	:

Provider Business Practice Location Address
First Line	:	1627 S UNION AVE
Second Line	:
City	:	ROSWELL
State	:	NM
Zip	:	88203-2656
Country	:	US
Telephone Number	:	575-625-3240
Fax Number	:

Authorized Official
Title or Position	:	EVP, GENERAL COUNSEL
Name	:	STEPHEN C. PETROVICH
Credential	:
Telephone Number	:	615-296-3594

Provider Enumeration Date	:	05/22/2023
Last Update Date	:	05/22/2023

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