Provider Demographics
NPI:1558616177
Name:SOUTHWEST CLINIC
Entity type:Organization
Organization Name:SOUTHWEST CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MGR
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-922-2999
Mailing Address - Street 1:207 SW MILITARY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-1615
Mailing Address - Country:US
Mailing Address - Phone:210-922-2999
Mailing Address - Fax:210-921-2419
Practice Address - Street 1:207 SW MILITARY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78221-1615
Practice Address - Country:US
Practice Address - Phone:210-922-2999
Practice Address - Fax:210-921-2419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5972207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty