Basic Information
| Provider Information | |||||||||
| NPI: | 1669536603 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNM HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CARRIE TINGLEY OUTPATIENT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 400 TIJERAS AVE NW STE 450 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722521 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1127 UNIVERSITY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725200 | ||||||||
| FaxNumber: | 5052723215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5052721840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | 6074 | NM | Y | Hospitals | Special Hospital |
ID Information
| ID | Type | State | Issuer | Description | 02156901 | 01 | NM | AHCCCS | OTHER | NM000062 | 01 | NM | BCBS | OTHER | 0003 | 01 | NM | CHAMPUS | OTHER | 62308 | 01 | NM | CIGNA | OTHER | 201080119 | 01 | NM | PRESBYTERIAN SALUD | OTHER | 450 | 01 | NM | LOVELACE SALUD | OTHER | 60054 | 01 | NM | AETNA | OTHER |