Provider Demographics
NPI:1346636578
Name:SOUTHWEST SPORTS AND SPINE
Entity Type:Organization
Organization Name:SOUTHWEST SPORTS AND SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-395-0512
Mailing Address - Street 1:5860 N LA CHOLLA BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3562
Mailing Address - Country:US
Mailing Address - Phone:520-395-0512
Mailing Address - Fax:520-505-4108
Practice Address - Street 1:400 W CAMINO CASA VERDE STE 100
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-3569
Practice Address - Country:US
Practice Address - Phone:520-395-0512
Practice Address - Fax:520-505-4108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34986174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ347495Medicaid
AZ347495Medicaid