Provider Demographics
NPI:1477595924
Name:SOUTHWESTERN NEUROSURGERY PHYSICIANS LLC
Entity Type:Organization
Organization Name:SOUTHWESTERN NEUROSURGERY PHYSICIANS LLC
Other - Org Name:SOUTHWESTERN NEUROSCIENCES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:O'SHAUGHNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-531-4600
Mailing Address - Street 1:5604 SW LEE BLVD
Mailing Address - Street 2:SUITE 357
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9681
Mailing Address - Country:US
Mailing Address - Phone:580-531-4600
Mailing Address - Fax:580-531-6405
Practice Address - Street 1:5604 SW LEE BLVD
Practice Address - Street 2:SUITE 357
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9681
Practice Address - Country:US
Practice Address - Phone:580-531-4600
Practice Address - Fax:580-531-6405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23774207T00000X
OK260132084N0400X
OK25895208600000X
OK25956208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200051010AMedicaid
OK200199360AMedicaid
OK200035200AMedicaid
B34917Medicare UPIN
OK200199360AMedicaid