Basic Information
| Provider Information | |||||||||
| NPI: | 1285714766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF NEW MEXICO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNM CANCER RESEARCH & TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | SUITE 2222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 CAMINO DE SALUD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871024517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724946 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | WHITEHEAD | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5052724443 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 04108051 | 05 | NM | MEDICAID |