Provider Demographics
NPI:1174707517
Name:SOUTHWEST FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:SOUTHWEST FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-569-9133
Mailing Address - Street 1:1575 W 7000 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3431
Mailing Address - Country:US
Mailing Address - Phone:801-569-9133
Mailing Address - Fax:801-569-9103
Practice Address - Street 1:1575 W 7000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-3431
Practice Address - Country:US
Practice Address - Phone:801-569-9133
Practice Address - Fax:801-569-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1756991205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1316986136OtherNPI REBECCA LEVINE, MD
UT000058107OtherMEDICARE GROUP NUMBER
UT1386691251OtherNPI KATIE JULIEN, MD
UT1952341000OtherNPI
UT1174707517OtherGROUP / CORP NPI
UT000057709OtherGROUP MEDICARE # JULIEN
UT000012547Medicare PIN
UT1316986136OtherNPI REBECCA LEVINE, MD
UTD87673Medicare UPIN
UT000057709Medicare PIN
UT1952341000OtherNPI
UT1174707517OtherGROUP / CORP NPI