1689666760 NPI number — RICHARD BUSH HOLMES MD

Table of content: RICHARD BUSH HOLMES MD (NPI 1689666760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689666760 NPI number — RICHARD BUSH HOLMES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLMES
Provider First Name:
RICHARD
Provider Middle Name:
BUSH
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:
1689666760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5400 GIBSON BLVD SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87108-4729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-262-7960
Provider Business Mailing Address Fax Number:
505-232-1368

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 MLK JR AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
ALBUQEURQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-262-7281
Provider Business Practice Location Address Fax Number:
505-262-7622
Provider Enumeration Date:
08/16/2005

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: 208600000X , with the licence number:  MD2009-0529 , 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)