1447568811 NPI number — MARK SEREDOWYCH, MD, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447568811 NPI number — MARK SEREDOWYCH, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK SEREDOWYCH, MD, 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:
1447568811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-4769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-982-4276
Provider Business Mailing Address Fax Number:
505-983-7571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-4769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-982-4276
Provider Business Practice Location Address Fax Number:
505-983-7571
Provider Enumeration Date:
09/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SEREDOWYCH
Authorized Official First Name:
MARK
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-982-4276

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  2000-289 , 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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