1124406269 NPI number — INTERNAL MEDICINE PREMIUM HEALTH CARE PC

Table of content: (NPI 1124406269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124406269 NPI number — INTERNAL MEDICINE PREMIUM HEALTH CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE PREMIUM HEALTH CARE PC
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:
1124406269
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 E LOHMAN AVE
Provider Second Line Business Mailing Address:
STE D
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88001-3394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
525-652-4426
Provider Business Mailing Address Fax Number:
525-222-0025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 E LOHMAN AVE
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88001-3394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
525-652-4426
Provider Business Practice Location Address Fax Number:
525-222-0025
Provider Enumeration Date:
05/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DARAG
Authorized Official First Name:
WENDI
Authorized Official Middle Name:
LASHEA GLASON
Authorized Official Title or Position:
MD, OWNER
Authorized Official Telephone Number:
575-652-4426

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD2013-0836 , 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)





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