Provider Demographics
NPI:1710176995
Name:SOUTHWEST OBSTETRICS AND GYNECOLOGY, LLC
Entity Type:Organization
Organization Name:SOUTHWEST OBSTETRICS AND GYNECOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-325-4898
Mailing Address - Street 1:634 W PINON ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5915
Mailing Address - Country:US
Mailing Address - Phone:505-325-4898
Mailing Address - Fax:505-325-7898
Practice Address - Street 1:634 W PINON ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5915
Practice Address - Country:US
Practice Address - Phone:505-325-4898
Practice Address - Fax:505-325-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0662207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12986062Medicaid