MEDICARE: SOUTHWESTERN OBSTETRICS AND GYNECOLOGY, 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	0700509	OTHER	ND	UNITED HEALTHCARE GROUP #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578555330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWESTERN OBSTETRICS AND GYNECOLOGY, INC.

Provider Business Mailing Address
First Line	:	4461 S. BROADWAY
Second Line	:	SUITE 200
City	:	GROVE CITY
State	:	OH
Zip	:	43123-3990
Country	:	US
Telephone Number	:	614-875-0444
Fax Number	:	614-875-1193

Provider Business Practice Location Address
First Line	:	4461 S. BROADWAY
Second Line	:	SUITE 200
City	:	GROVE CITY
State	:	OH
Zip	:	43123-3990
Country	:	US
Telephone Number	:	614-875-0444
Fax Number	:	614-875-1193

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. TERESA DIENER
Credential	:
Telephone Number	:	614-875-0444

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	07/12/2007

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