1881998664 NPI number — DR. TOM CHILD AND ADOLESCENT MEDICINE

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 1881998664 NPI number — DR. TOM CHILD AND ADOLESCENT MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. TOM CHILD AND ADOLESCENT 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:
1881998664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
199 SAN ILDEFONSO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ALAMOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87544-2735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-412-3367
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
LOS ALAMOS MEDICAL CENTER, 3917 WEST RD
Provider Second Line Business Practice Location Address:
SUITE M250
Provider Business Practice Location Address City Name:
LOS ALAMOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87544
Provider Business Practice Location Address Country Code:
UM
Provider Business Practice Location Address Telephone Number:
505-412-3367
Provider Business Practice Location Address Fax Number:
505-662-9200
Provider Enumeration Date:
01/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HARRISON
Authorized Official First Name:
MARVEL
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
505-412-3367

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  93244 , 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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