Provider Demographics
NPI:1134582570
Name:SOUTHWEST SPINE AND PAIN CARE SPECIALISTS LLC
Entity type:Organization
Organization Name:SOUTHWEST SPINE AND PAIN CARE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:OBTAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-656-2424
Mailing Address - Street 1:652 S MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7049
Mailing Address - Country:US
Mailing Address - Phone:435-656-2424
Mailing Address - Fax:535-787-8149
Practice Address - Street 1:630 E 1400 N
Practice Address - Street 2:SUITE 135
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2534
Practice Address - Country:US
Practice Address - Phone:435-656-2424
Practice Address - Fax:535-787-8149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-02
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty