Basic Information
| Provider Information | |||||||||
| NPI: | 1669614947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF NEW MEXICO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1408 MANZANO ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871105019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052720011 | ||||||||
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| Practice Location | |||||||||
| Address1: | DEPT OF RADIOLOGY MSC10 5530 | ||||||||
| Address2: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052720011 | ||||||||
| FaxNumber: | 5052725821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 04/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | WIEST | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 5052720011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | MD2009-0062 | NM | Y | Hospitals | General Acute Care Hospital |
No ID Information.