Provider Demographics
NPI:1629235841
Name:SOUTHWESTERN ANESTHESIA GROUP (SWAG)
Entity Type:Organization
Organization Name:SOUTHWESTERN ANESTHESIA GROUP (SWAG)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-792-3914
Mailing Address - Street 1:3465 TORRANCE BLVD STE S
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5804
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:310-792-3802
Practice Address - Street 1:5725 SOTO ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2630
Practice Address - Country:US
Practice Address - Phone:323-587-9566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicaid