Provider Demographics
NPI:1811027808
Name:SOUTHWEST MEDICAL SPECIALISTS, SC
Entity type:Organization
Organization Name:SOUTHWEST MEDICAL SPECIALISTS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MELICHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-423-2258
Mailing Address - Street 1:6311 W 95TH STREET
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2201
Mailing Address - Country:US
Mailing Address - Phone:708-423-2258
Mailing Address - Fax:708-423-2305
Practice Address - Street 1:6311 W 95TH STREET
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2201
Practice Address - Country:US
Practice Address - Phone:708-423-2258
Practice Address - Fax:708-423-2305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
IL042006686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
928040Medicare PIN