Provider Demographics
NPI:1124096334
Name:SOUTHWEST MEDICAL CLINIC,INC.
Entity type:Organization
Organization Name:SOUTHWEST MEDICAL CLINIC,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:OBINNA
Authorized Official - Middle Name:BONIFACE
Authorized Official - Last Name:UBANI-EBERE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-672-4818
Mailing Address - Street 1:7007 WILLIAMS STREET
Mailing Address - Street 2:SUITE C, BOX 1120
Mailing Address - City:GREENVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30222
Mailing Address - Country:US
Mailing Address - Phone:706-672-4818
Mailing Address - Fax:706-672-4818
Practice Address - Street 1:7007 WILLIAMS STREET
Practice Address - Street 2:SUITE C, BOX 1120
Practice Address - City:GREENVILLE
Practice Address - State:GA
Practice Address - Zip Code:30222
Practice Address - Country:US
Practice Address - Phone:706-672-4818
Practice Address - Fax:706-672-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042618207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6433Medicare ID - Type UnspecifiedGROUP