Provider Demographics
NPI:1104105873
Name:SWAN UROGYNECOLOGY, PC
Entity type:Organization
Organization Name:SWAN UROGYNECOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONDRAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:615-515-9180
Mailing Address - Street 1:329 21ST AVENUE NORTH
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1857
Mailing Address - Country:US
Mailing Address - Phone:615-515-9180
Mailing Address - Fax:615-712-7647
Practice Address - Street 1:329 21ST AVENUE NORTH
Practice Address - Street 2:SUITE 1
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1857
Practice Address - Country:US
Practice Address - Phone:615-515-9180
Practice Address - Fax:615-712-7647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1526073Medicaid
TN5347655OtherAETNA
TN4296723OtherBCBS
TN1104105873OtherMEDICARE