1396799938 NPI number — PREMIER OB/GYN, LLC

Table of content: (NPI 1396799938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396799938 NPI number — PREMIER OB/GYN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER OB/GYN, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1396799938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5419 N LOVINGTON HWY
Provider Second Line Business Mailing Address:
COMPLEX # 5, SUITE 6
Provider Business Mailing Address City Name:
HOBBS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88240-9100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-392-6600
Provider Business Mailing Address Fax Number:
505-392-4071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5419 N LOVINGTON HWY
Provider Second Line Business Practice Location Address:
COMPLEX # 5, SUITE 6
Provider Business Practice Location Address City Name:
HOBBS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88240-9100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-392-6600
Provider Business Practice Location Address Fax Number:
505-392-4071
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAID
Authorized Official First Name:
ELIAS
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
505-392-6600

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  NM2003-0670 , 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: $$$$$$$$$ . This is a "SOCIAL SECURITY NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 207V00000X . This is a "TAXANOMY CODE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: $$$$$$$$$ . This is a "SOCIAL SECURITY NUMBER" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 88422747 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43805809 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6677206 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: $$$$$$$$$ . This is a "SOCIAL SECURITY NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 207V00000X . This is a "TAXONOMY CODE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 363LW0102X . This is a "TAXONOMY CODE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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