Provider Demographics
NPI:1215025390
Name:SOUTHWEST FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:SOUTHWEST FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:CASSIDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-324-1100
Mailing Address - Street 1:304 N. LOCKE AVE.
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-324-1100
Mailing Address - Fax:505-324-1117
Practice Address - Street 1:304 N. LOCKE AVE.
Practice Address - Street 2:FARMINGTON
Practice Address - City:FARMINTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-324-1100
Practice Address - Fax:505-324-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM207Q00000X
NM97-202208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR7312Medicaid
G68017Medicare UPIN
NMR7312Medicaid