Basic Information
| Provider Information | |||||||||
| NPI: | 1497910848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIO GRANDE DERMATOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4545 ALAMEDA BLVD NE | ||||||||
| Address2: | SUITE G | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871131591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058962900 | ||||||||
| FaxNumber: | 5059384198 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 ALAMEDA BLVD NE | ||||||||
| Address2: | SUITE G | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871131591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058962900 | ||||||||
| FaxNumber: | 5059384198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2008 | ||||||||
| LastUpdateDate: | 02/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | MONTANO | ||||||||
| AuthorizedOfficialFirstName: | FRANCINE | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5058962900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 20050405 | NM | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 20020450 | NM | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 47235306 | 05 | NM | MEDICAID | 76659755 | 05 | NM | MEDICAID |