Provider Demographics
NPI:1245316447
Name:SOUTHWESTERN MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHWESTERN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP REIMBURSEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHELTON
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-764-3009
Mailing Address - Street 1:5602 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9635
Mailing Address - Country:US
Mailing Address - Phone:580-531-4700
Mailing Address - Fax:
Practice Address - Street 1:5602 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9635
Practice Address - Country:US
Practice Address - Phone:580-531-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWESTERN MEDICAL CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-31
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2231323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100697950FMedicaid