Basic Information
| Provider Information | |||||||||
| NPI: | 1447242839 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHOVER | ||||||||
| FirstName: | DANIEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059235356 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | PMG CEDAR PEDIATRIC GI | ||||||||
| Address2: | 201 CEDAR SE SUITE 302 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055636550 | ||||||||
| FaxNumber: | 5055636551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | MD2005-0835 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 208000000X | MD2005-0835 | NM | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 99752719 | 05 | NM | MEDICAID |