Basic Information
| Provider Information | |||||||||
| NPI: | 1639610702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST GENERAL MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638269 | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452638269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402892025 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18697 BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408168200 | ||||||||
| FaxNumber: | 4408168197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2017 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4408164906 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 50005004 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.