1366439978 NPI number — DANIEL E RAES MD

Table of content: DANIEL E RAES MD (NPI 1366439978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366439978 NPI number — DANIEL E RAES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAES
Provider First Name:
DANIEL
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1366439978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 W COUNTRY CLUB RD
Provider Second Line Business Mailing Address:
C/O MSO ADMINISTRATION
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88201-5209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-624-4777
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 W COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
SUITE# 220
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88201-5202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-625-1292
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2005

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: 207Q00000X , with the licence number:  94-126 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30722 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NPI# . This is a "BCBS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".