Provider Demographics
NPI:1457427387
Name:SOUTHWEST MOBILE DIAGNOSTIC
Entity Type:Organization
Organization Name:SOUTHWEST MOBILE DIAGNOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCELO
Authorized Official - Middle Name:LAPURGA
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:JR
Authorized Official - Credentials:SONAGRAPHER
Authorized Official - Phone:276-322-4520
Mailing Address - Street 1:PO BOX 797
Mailing Address - Street 2:
Mailing Address - City:NORTH TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24630-0797
Mailing Address - Country:US
Mailing Address - Phone:276-322-4520
Mailing Address - Fax:276-322-4520
Practice Address - Street 1:RR2 RIVERBEND
Practice Address - Street 2:EST NO 26
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-0026
Practice Address - Country:US
Practice Address - Phone:276-322-4520
Practice Address - Fax:276-322-4520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0036569000Medicaid
VA004990200Medicaid
WVID00021Medicare PIN