1447430509 NPI number — ROSWELL EAR, NOSE & THROAT & ALLERGY L. L. C.

Table of content: (NPI 1447430509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447430509 NPI number — ROSWELL EAR, NOSE & THROAT & ALLERGY L. L. C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSWELL EAR, NOSE & THROAT & ALLERGY L. L. C.
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:
1447430509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
342 SHERRILL LN STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88201-5831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-622-2911
Provider Business Mailing Address Fax Number:
575-622-2598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
342 SHERRILL LN STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88201-5831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-622-2911
Provider Business Practice Location Address Fax Number:
575-622-2598
Provider Enumeration Date:
11/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOBBS
Authorized Official First Name:
JAN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
575-622-2911

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  CS00208445 , 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: 90859561 . This is a "MEDICAID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM009D18 . This is a "BCBS OF NEW MEXICO" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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