Provider Demographics
NPI:1649700816
Name:SOUTHWESTERN ORTHOPEDIC MEDICAL GROUP
Entity type:Organization
Organization Name:SOUTHWESTERN ORTHOPEDIC MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RISK MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-967-3442
Mailing Address - Street 1:1 HIDDEN HILLS CIR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4821
Mailing Address - Country:US
Mailing Address - Phone:909-967-3442
Mailing Address - Fax:951-443-4779
Practice Address - Street 1:1 HIDDEN HILLS CIR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-4821
Practice Address - Country:US
Practice Address - Phone:909-967-3442
Practice Address - Fax:951-443-4779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty