Provider Demographics
NPI:1689907081
Name:MIKE SWANN, MD, LLC
Entity Type:Organization
Organization Name:MIKE SWANN, MD, LLC
Other - Org Name:SWANN DERMATOLOGY & ESTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:SWANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-888-0858
Mailing Address - Street 1:3850 S NATIONAL AVE
Mailing Address - Street 2:SUITE 705
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5287
Mailing Address - Country:US
Mailing Address - Phone:417-888-0858
Mailing Address - Fax:417-889-0476
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:SUITE 705
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-888-0858
Practice Address - Fax:417-889-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007005538207NS0135X
MO26D2031359291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty