Provider Demographics
NPI:1104823939
Name:SOUTHWEST HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:SOUTHWEST HEALTH SYSTEM, INC.
Other - Org Name:CORTEZ PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUDDUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-564-2150
Mailing Address - Street 1:1311 N MILDRED RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2231
Mailing Address - Country:US
Mailing Address - Phone:970-564-2152
Mailing Address - Fax:970-564-2155
Practice Address - Street 1:118 N CHESTNUT
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321
Practice Address - Country:US
Practice Address - Phone:970-564-9777
Practice Address - Fax:970-564-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19961032821261Q00000X
CO11206282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04020020Medicaid
CO05002050Medicaid
CO04143012Medicaid
CO06600183Medicaid
G4004Medicare ID - Type Unspecified
CO06600183Medicaid
CO06Z327Medicare Oscar/Certification
CO060018Medicare Oscar/Certification
CO061327Medicare Oscar/Certification