Provider Demographics
NPI:1720327059
Name:SOUTHWEST PHYSICIAN GROUP PA
Entity type:Organization
Organization Name:SOUTHWEST PHYSICIAN GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHENER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:915-855-2400
Mailing Address - Street 1:3270 JOE BATTLE BLVD
Mailing Address - Street 2:205
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-2639
Mailing Address - Country:US
Mailing Address - Phone:915-855-2400
Mailing Address - Fax:915-855-2401
Practice Address - Street 1:3270 JOE BATTLE BLVD
Practice Address - Street 2:205
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-2639
Practice Address - Country:US
Practice Address - Phone:915-855-2400
Practice Address - Fax:915-855-2401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2838207V00000X
TXM7798208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM7798OtherTX MEDICAL LICENSE M7798