Basic Information
| Provider Information | |||||||||
| NPI: | 1144212473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAS CRUCES ORTHOPAEDIC ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1560 | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880041560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755253535 | ||||||||
| FaxNumber: | 5055270217 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 AVENIDA DE MESILLA | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755253535 | ||||||||
| FaxNumber: | 5055270217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | STACK | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5755253535 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | L3521 | 05 | NM | MEDICAID |