1114977675 NPI number — EASTERN NEW MEXICO PHYSICIANS AND SURGEONS LLC

Table of content: (NPI 1114977675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114977675 NPI number — EASTERN NEW MEXICO PHYSICIANS AND SURGEONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN NEW MEXICO PHYSICIANS AND SURGEONS 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:
1114977675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2425 W 21ST STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-763-9800
Provider Business Mailing Address Fax Number:
505-769-1998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 W 21ST STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-763-9800
Provider Business Practice Location Address Fax Number:
505-769-1998
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAY
Authorized Official First Name:
LONNIE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
505-763-9800

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 78904374 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00NM001B06 . This is a "BCBS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 03-07242-6000 . This is a "CRS-1 NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: DF1773 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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