Provider Demographics
NPI:1639236425
Name:SOUTHWEST VASCULAR AND SURGICAL GROUP
Entity Type:Organization
Organization Name:SOUTHWEST VASCULAR AND SURGICAL GROUP
Other - Org Name:DALLAS SURGICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-566-8039
Mailing Address - Street 1:7777 FOREST LANE
Mailing Address - Street 2:SUITE C-760
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-6801
Mailing Address - Country:US
Mailing Address - Phone:972-566-8039
Mailing Address - Fax:972-566-2312
Practice Address - Street 1:7777 FOREST LANE
Practice Address - Street 2:SUITE C-760
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6801
Practice Address - Country:US
Practice Address - Phone:972-566-8039
Practice Address - Fax:972-566-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6012208600000X
TXJ0020208600000X
TXJ3706208600000X
TXK9914208600000X
TXL38392086S0129X
TXH22392086X0206X
TXK7546208C00000X
TXE3311208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083607401Medicaid
TX083607401Medicaid
TX00K98JMedicare PIN