Provider Demographics
NPI:1467652032
Name:SOUTHWEST NEUROLOGY, PA
Entity Type:Organization
Organization Name:SOUTHWEST NEUROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-412-8700
Mailing Address - Street 1:6701 HERITAGE PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-8799
Mailing Address - Country:US
Mailing Address - Phone:972-412-8700
Mailing Address - Fax:972-412-9700
Practice Address - Street 1:6701 HERITAGE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-8799
Practice Address - Country:US
Practice Address - Phone:972-412-8700
Practice Address - Fax:972-412-9700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9378174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00431XMedicare PIN