Basic Information
| Provider Information | |||||||||
| NPI: | 1578644415 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAGE NEUROSCIENCE CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7850 JEFFERSON ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058841114 | ||||||||
| FaxNumber: | 5053593010 | ||||||||
| Practice Location | |||||||||
| Address1: | 7850 JEFFERSON ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058841114 | ||||||||
| FaxNumber: | 5053593010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 07/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | SUTTER | ||||||||
| AuthorizedOfficialFirstName: | REUBEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5058841114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MD2005-0751 | NM | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1962463877 | 01 | NM | INDIVIDUAL NPI | OTHER |