Provider Demographics
NPI:1083640601
Name:SOUTHWESTERN PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:SOUTHWESTERN PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-844-9800
Mailing Address - Street 1:5602 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9635
Mailing Address - Country:US
Mailing Address - Phone:580-531-6408
Mailing Address - Fax:580-531-4981
Practice Address - Street 1:5602 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9635
Practice Address - Country:US
Practice Address - Phone:580-531-6408
Practice Address - Fax:580-531-4981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2231207L00000X, 207Q00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200006730AMedicaid
OK200006730AMedicaid