Provider Demographics
NPI:1679686182
Name:SOUTHWEST GASTROENTEROLOGY, LLC
Entity Type:Organization
Organization Name:SOUTHWEST GASTROENTEROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:XUJUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-409-3337
Mailing Address - Street 1:2817 MC CLELLAND BLVD
Mailing Address - Street 2:SUITE 153
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1629
Mailing Address - Country:US
Mailing Address - Phone:417-206-4928
Mailing Address - Fax:417-206-4734
Practice Address - Street 1:2817 MC CLELLAND BLVD
Practice Address - Street 2:SUITE 153
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1629
Practice Address - Country:US
Practice Address - Phone:417-206-4928
Practice Address - Fax:417-206-4734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006024391207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2006024391OtherSTATE OF MO LICENSE
OH2514363Medicaid
MO2006024391OtherSTATE OF MO LICENSE
OH2514363Medicaid
MO9352711Medicare ID - Type Unspecified