Provider Demographics
NPI:1275563975
Name:SOUTHWEST I.D. & MEDICAL CLINIC, LC
Entity Type:Organization
Organization Name:SOUTHWEST I.D. & MEDICAL CLINIC, LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALPANA
Authorized Official - Middle Name:
Authorized Official - Last Name:JETLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-772-3340
Mailing Address - Street 1:PO BOX 1629
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86302-1629
Mailing Address - Country:US
Mailing Address - Phone:928-772-3340
Mailing Address - Fax:
Practice Address - Street 1:3235 N WINDSONG DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-1222
Practice Address - Country:US
Practice Address - Phone:928-772-3340
Practice Address - Fax:928-759-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29064207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ109983Medicare PIN