Basic Information
| Provider Information | |||||||||
| NPI: | 1477624757 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST SURGICAL ASSOCIATES LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13811 MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774774903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7132556310 | ||||||||
| FaxNumber: | 7132556315 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 SOUTHWEST FWY | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770741802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137721200 | ||||||||
| FaxNumber: | 7132556335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | VAIL | ||||||||
| AuthorizedOfficialFirstName: | PRISCILLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MGR | ||||||||
| AuthorizedOfficialTelephone: | 7132556310 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 77074A001 | 01 | TX | GROUP TRICARE ID# | OTHER | 083465701 | 05 | TX | MEDICAID | CS7997 | 01 | TX | RR MEDICARE PIN | OTHER |