Provider Demographics
NPI:1184807745
Name:SOUTHWEST INDEPENDENT PRACTICE ASSOC
Entity type:Organization
Organization Name:SOUTHWEST INDEPENDENT PRACTICE ASSOC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT FOOT AND ANKLE GROUP
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:239-936-5400
Mailing Address - Street 1:5238 MASON CORBIN CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7738
Mailing Address - Country:US
Mailing Address - Phone:239-936-5400
Mailing Address - Fax:239-936-9572
Practice Address - Street 1:5238 MASON CORBIN CT
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7738
Practice Address - Country:US
Practice Address - Phone:239-936-5400
Practice Address - Fax:239-936-9572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty