Provider Demographics
NPI:1588713325
Name:SOUTHWEST GENERAL MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SOUTHWEST GENERAL MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-816-4906
Mailing Address - Street 1:PO BOX 638269
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-8269
Mailing Address - Country:US
Mailing Address - Phone:330-558-0070
Mailing Address - Fax:
Practice Address - Street 1:4065 CENTER RD.
Practice Address - Street 2:#210
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44212
Practice Address - Country:US
Practice Address - Phone:330-558-0050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST GENERAL MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-10
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2238206Medicaid
OH9932028Medicare PIN