1104973403 NPI number — REBECCA GEBALLE AA

Table of content: REBECCA GEBALLE AA (NPI 1104973403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104973403 NPI number — REBECCA GEBALLE AA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEBALLE
Provider First Name:
REBECCA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104973403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2211 LOMAS BLVD NE
Provider Second Line Business Mailing Address:
MSC 10 6000
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87106-2719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-272-2610
Provider Business Mailing Address Fax Number:
505-272-1300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
933 BRADBURY SE
Provider Second Line Business Practice Location Address:
SUITE 2222
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87106-2719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-272-3120
Provider Business Practice Location Address Fax Number:
505-272-8060
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367H00000X , with the licence number:  004393 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: AA2009-001 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 655260227A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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