1326044512 NPI number — INFECTIOUS DISEASES AND INTERNAL MEDICINE

Table of content: (NPI 1326044512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326044512 NPI number — INFECTIOUS DISEASES AND INTERNAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFECTIOUS DISEASES AND INTERNAL MEDICINE
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:
1326044512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5901 HARPER DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87109-3587
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-848-3730
Provider Business Mailing Address Fax Number:
505-848-3732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5901 HARPER DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87109-3587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-848-3730
Provider Business Practice Location Address Fax Number:
505-848-3732
Provider Enumeration Date:
06/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BACK
Authorized Official First Name:
JANIVA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
505-848-3730

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  78-15 , 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)





Copyright © 2007-2024 www.npivalidator.com