Basic Information
Provider Information | |||||||||
NPI: | 1447464664 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNM HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNMH PSYCHIATRIC UNIT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 TIJERAS AVE NW STE 450 | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871023273 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052724275 | ||||||||
FaxNumber: | 5052729991 | ||||||||
Practice Location | |||||||||
Address1: | 2600 MARBLE AVE., N.E. | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871062058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052722861 | ||||||||
FaxNumber: | 5052722016 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2007 | ||||||||
LastUpdateDate: | 01/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITE | ||||||||
AuthorizedOfficialFirstName: | BONNIE | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5052721840 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | UNM HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | NM-10004-M | NM | N |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 273R00000X |   |   | N |   | Hospital Units | Psychiatric Unit |   | 273R00000X | 6005 | NM | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 28350839 | 05 | NM |   | MEDICAID | 00092 | 05 | NM |   | MEDICAID |