Basic Information
Provider Information | |||||||||
NPI: | 1649431677 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF NEW MEXICO MEDICAL GROUP, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | UNIVERSITY OF NEW MEXICO SCHOOL BASED HEALTH CTRS | ||||||||
Address2: | MSC09 5040 1 UNIVERSITY OF NEW MEXICO | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871310001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052720457 | ||||||||
FaxNumber: | 5052722043 | ||||||||
Practice Location | |||||||||
Address1: | 4700 COAL AVE SE | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871082804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052563363 | ||||||||
FaxNumber: | 5052563363 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2008 | ||||||||
LastUpdateDate: | 06/23/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MASCIOTRA | ||||||||
AuthorizedOfficialFirstName: | ANTHONY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5052728950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | 88-PA05 | NM | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
ID | Type | State | Issuer | Description | 3A02 | 05 | NM |   | MEDICAID |