1821045329 NPI number — ALBUQUERQUE DERMATOLOGY ASSOCIATES, PA

Table of content: (NPI 1821045329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821045329 NPI number — ALBUQUERQUE DERMATOLOGY ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALBUQUERQUE DERMATOLOGY ASSOCIATES, PA
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:
1821045329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4610 JEFFERSON LN 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:
87109-2117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-872-4700
Provider Business Mailing Address Fax Number:
505-872-4709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4610 JEFFERSON LN 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:
87109-2117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-872-4700
Provider Business Practice Location Address Fax Number:
505-872-4709
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
ESTELLE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
505-872-4700

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  2002-0450 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: R46867NM , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: MD2005-0405 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: 2000-166 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X , with the licence number: 2000-166 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: 2000-166 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: 2002-0450 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: R46867NM , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: MD2005-0405 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 76659755 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: F1418 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44792 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47235306 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 93885865 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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