1891753836 NPI number — ELLEN RHEA WARREN MD

Table of content: ELLEN RHEA WARREN MD (NPI 1891753836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891753836 NPI number — ELLEN RHEA WARREN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARREN
Provider First Name:
ELLEN
Provider Middle Name:
RHEA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1891753836
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/17/2007
NPI Reactivation Date:
08/03/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 PASEO DEL PUEBLO SUR
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
TAOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87571-6070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-758-3005
Provider Business Mailing Address Fax Number:
575-758-7010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 PASEO DEL PUEBLO SUR
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
TAOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87571-6070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-758-3005
Provider Business Practice Location Address Fax Number:
575-758-7010
Provider Enumeration Date:
05/01/2006

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:  82-332 , 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: 09167 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080098206 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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