1710126248 NPI number — NEW MEXICO MEDWORKS

Table of content: (NPI 1710126248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710126248 NPI number — NEW MEXICO MEDWORKS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW MEXICO MEDWORKS
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:
SANTA FE MEDICAL GROUP
Provider Other Organization Name Type Code:
5
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:
1710126248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 RODEO RD
Provider Second Line Business Mailing Address:
SUITE C-13
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87507-6503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-474-4251
Provider Business Mailing Address Fax Number:
505-473-0928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 RODEO LN
Provider Second Line Business Practice Location Address:
SUITE A-1
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87507-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-474-6097
Provider Business Practice Location Address Fax Number:
505-471-4503
Provider Enumeration Date:
02/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GURULE
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SPECIALIST
Authorized Official Telephone Number:
505-474-6097

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , 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: 46233 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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