Provider Demographics
NPI:1831375237
Name:SOUTHWEST BACK & NECK CLINC, PA
Entity type:Organization
Organization Name:SOUTHWEST BACK & NECK CLINC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-861-2752
Mailing Address - Street 1:6642 PENN AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2026
Mailing Address - Country:US
Mailing Address - Phone:612-861-2752
Mailing Address - Fax:
Practice Address - Street 1:6642 PENN AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2026
Practice Address - Country:US
Practice Address - Phone:612-861-2752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN002891261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1033321096OtherINDIVIDUAL NPI
U19849Medicare UPIN
350003466Medicare PIN