Provider Demographics
NPI:1346287794
Name:SOUTHWEST INTERNAL MEDICINE P A
Entity Type:Organization
Organization Name:SOUTHWEST INTERNAL MEDICINE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-945-5940
Mailing Address - Street 1:1708 CAPE CORAL PKWY W
Mailing Address - Street 2:#4
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-6985
Mailing Address - Country:US
Mailing Address - Phone:239-945-5940
Mailing Address - Fax:239-945-5941
Practice Address - Street 1:1708 CAPE CORAL PKWY W
Practice Address - Street 2:#4
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-6985
Practice Address - Country:US
Practice Address - Phone:239-945-5940
Practice Address - Fax:239-945-5941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC236Medicare PIN
DF8425Medicare PIN