Provider Demographics
NPI:1760603054
Name:SOUTHWEST MEDICAL AFFILIATES, PC
Entity Type:Organization
Organization Name:SOUTHWEST MEDICAL AFFILIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:L
Authorized Official - Last Name:MORIARTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-857-5804
Mailing Address - Street 1:5630 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2406
Mailing Address - Country:US
Mailing Address - Phone:708-857-5800
Mailing Address - Fax:708-857-5805
Practice Address - Street 1:5630 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2406
Practice Address - Country:US
Practice Address - Phone:708-857-5800
Practice Address - Fax:708-857-5805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063034207R00000X
IL036063793208000000X
IL016004378213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1407861982OtherNPI
IL036063034Medicaid
IL1629084116OtherNPI
IL1972519486OtherNPI
IL016004378Medicaid
IL036063793Medicaid
IL036063034Medicaid
IL016004378Medicaid
4334360001Medicare NSC
IL1407861982OtherNPI
ILE60974Medicare UPIN