Basic Information
| Provider Information | |||||||||
| NPI: | 1245213750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHERIDAN CHILDREN HEALTHCARE SERVICES OF NEW MEXICO INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 452036 | ||||||||
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| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333452036 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4701 MONTGOMERY BLVD NE | ||||||||
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| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871091219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548382371 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 04/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | COWARD | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9548382371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | NM007D87 | 01 | NM | BC/BS | OTHER | 98583824 | 05 | NM | MEDICAID |