Provider Demographics
NPI:1033448576
Name:SOUTHWEST SPORTS AND SPINE LLC
Entity Type:Organization
Organization Name:SOUTHWEST SPORTS AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-395-0512
Mailing Address - Street 1:PO BOX 70232
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-0030
Mailing Address - Country:US
Mailing Address - Phone:520-395-0512
Mailing Address - Fax:520-505-4108
Practice Address - Street 1:5860 N LA CHOLLA BLVD STE 150
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3562
Practice Address - Country:US
Practice Address - Phone:520-395-0512
Practice Address - Fax:520-505-4108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ208100000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ498019Medicaid
AZZ135694Medicare PIN