1891925848 NPI number — G MICHAEL LOPEZ

Table of content: (NPI 1891925848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891925848 NPI number — G MICHAEL LOPEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G MICHAEL LOPEZ
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:
1891925848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 MILLS AVE # 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-425-9311
Provider Business Mailing Address Fax Number:
505-425-9047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 MILLS AVE STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87701-4169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-425-9311
Provider Business Practice Location Address Fax Number:
505-425-9047
Provider Enumeration Date:
07/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
G MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-425-9311

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  NM81-770 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 92PA09 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: R53421 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: NM001568 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 201006000 . This is a "PRESBYTERIAN HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 00007070 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM001568 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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