Basic Information
| Provider Information | |||||||||
| NPI: | 1477788644 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RURAL RADIOLOGY ASSOCIATES TAOS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12687 W CEDAR DR | ||||||||
| Address2: | 200 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802282014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034681395 | ||||||||
| FaxNumber: | 3034681394 | ||||||||
| Practice Location | |||||||||
| Address1: | 1397 WEIMAR RD | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875716253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757588883 | ||||||||
| FaxNumber: | 3034681394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2009 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CO OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5757588883 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/20/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 64108236 | 05 | NM | MEDICAID |