Basic Information
| Provider Information | |||||||||
| NPI: | 1376569921 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALBUQUERQUE UROLOGY ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 BROADWAY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052423991 | ||||||||
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| Practice Location | |||||||||
| Address1: | 610 BROADWAY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052423991 | ||||||||
| FaxNumber: | 5052438405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 07/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | LACKNER | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER / M.D. | ||||||||
| AuthorizedOfficialTelephone: | 5052423991 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 6682460001 | NM | N | Suppliers | Durable Medical Equipment & Medical Supplies | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 44361 | 05 | NM | MEDICAID | CS1373 | 01 | NM | RAILROAD MEDICARE | OTHER |