Basic Information
| Provider Information | |||||||||
| NPI: | 1467682237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW MEXICO VA HEALTHCARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 CARDENAS DR SE | ||||||||
| Address2: | APT 313 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871084736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753130916 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO DR SE | ||||||||
| Address2: | AMBULATORY CARE (115) | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871085153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | 5052562888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 07/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | SCHIMMEL | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF AMBULATORY CARE | ||||||||
| AuthorizedOfficialTelephone: | 5052651711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | R27976 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | VA |
No ID Information.