Provider Demographics
NPI:1508915364
Name:SOUTHWEST GENERAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SOUTHWEST GENERAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-816-4906
Mailing Address - Street 1:PO BOX 638269
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:440-816-4930
Mailing Address - Fax:
Practice Address - Street 1:18181 PEARL RD
Practice Address - Street 2:B206
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-6949
Practice Address - Country:US
Practice Address - Phone:440-816-4930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2238162Medicaid
OH2238144Medicaid
OH9932029Medicare PIN
OH2238162Medicaid