Provider Demographics
NPI:1467637280
Name:SOUTHWEST NEUROLOGY P C
Entity Type:Organization
Organization Name:SOUTHWEST NEUROLOGY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-788-4260
Mailing Address - Street 1:PO BOX 10499
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-0499
Mailing Address - Country:US
Mailing Address - Phone:928-788-4260
Mailing Address - Fax:928-788-4262
Practice Address - Street 1:5300 S HIGHWAY 95
Practice Address - Street 2:SUITE L
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9251
Practice Address - Country:US
Practice Address - Phone:928-788-4260
Practice Address - Fax:928-788-4262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ227882084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ215691002Medicaid
AZ1415509-3OtherCORPORATION REGISTRATION
AZZ120388Medicare PIN