Provider Demographics
NPI:1689805194
Name:SOUTHWEST SPINE AND SPORTS
Entity Type:Organization
Organization Name:SOUTHWEST SPINE AND SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-860-8998
Mailing Address - Street 1:PO BOX 52001
Mailing Address - Street 2:DEPT 901
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2001
Mailing Address - Country:US
Mailing Address - Phone:480-860-8998
Mailing Address - Fax:480-377-9245
Practice Address - Street 1:1025 E BROADWAY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1599
Practice Address - Country:US
Practice Address - Phone:480-860-8998
Practice Address - Fax:480-377-9245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6238140002Medicare NSC
AZ71519Medicare PIN