Basic Information
| Provider Information | |||||||||
| NPI: | 1720614241 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST PREMIER UROLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43100 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857333100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207223777 | ||||||||
| FaxNumber: | 5202966224 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 N EL DORADO PL | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857154606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203244660 | ||||||||
| FaxNumber: | 5203244659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2020 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | BERRY | ||||||||
| AuthorizedOfficialFirstName: | TRISTAN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5203244660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.