Basic Information
| Provider Information | |||||||||
| NPI: | 1164754453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW MEXICO RHEUMATOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8200 LOUISIANA BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871132105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058282400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8200 LOUISIANA BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871132105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058282400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2010 | ||||||||
| LastUpdateDate: | 11/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROSANDICH | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4047596866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | MD20050123 | NM | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 78834295 | 05 | NM | MEDICAID | 1356435747 | 01 | NPI-PERSONAL | OTHER |