Basic Information
| Provider Information | |||||||||
| NPI: | 1275010985 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAIN STREET ANESTHESIA OF NEW MEXICO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 225135 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752225135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553974154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 DR MARTIN LUTHER KING JR AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057278000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2018 | ||||||||
| LastUpdateDate: | 11/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | LEACHMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | PATRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5756441983 | ||||||||
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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 | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.