Basic Information
| Provider Information | |||||||||
| NPI: | 1114934254 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW MEXICO MEDICAL SURGICAL HOSPITAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROSWELL REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882015151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756253308 | ||||||||
| FaxNumber: | 5756277007 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882015151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056277000 | ||||||||
| FaxNumber: | 5056277007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 03/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 1T 3252 | NM | N | Hospitals | General Acute Care Hospital | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 07707576 | 05 | NM | MEDICAID |