1801427695 NPI number — STACIA ROUM

Table of content: RACHEL ELIZABETH GELFOND DAVIDGE D.O. (NPI 1013304286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801427695 NPI number — STACIA ROUM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUM
Provider First Name:
STACIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1801427695
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 237
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL RITO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87530-0237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-581-4728
Provider Business Mailing Address Fax Number:
575-581-0030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NM 571 BLDG 28
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL RITO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-581-4728
Provider Business Practice Location Address Fax Number:
575-581-0030
Provider Enumeration Date:
01/30/2020

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: 104100000X , with the licence number:  M10379 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: C-11362 , 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: 49475053 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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