Provider Demographics
NPI:1114236759
Name:SOUTHWEST FAMILY CLINIC
Entity Type:Organization
Organization Name:SOUTHWEST FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:D,O
Authorized Official - Phone:405-682-4651
Mailing Address - Street 1:2149 SW 59TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-7033
Mailing Address - Country:US
Mailing Address - Phone:405-682-4651
Mailing Address - Fax:405-682-3391
Practice Address - Street 1:2149 SW 59TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-7033
Practice Address - Country:US
Practice Address - Phone:405-682-4651
Practice Address - Fax:405-682-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1648204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE09754Medicare UPIN