Basic Information
| Provider Information | |||||||||
| NPI: | 1770841728 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNM HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2211 LOMAS BLVD., 3RD FLOOR | ||||||||
| Address2: | UNM HOSPITAL-PEDIATRIC NEUROLOGY | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722325 | ||||||||
| FaxNumber: | 5052771363 | ||||||||
| Practice Location | |||||||||
| Address1: | UNM HOSPITAL PEDIATRIC NEUROLOGY | ||||||||
| Address2: | 2211 LOMAS BLVD., 3RD FLOOR | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722325 | ||||||||
| FaxNumber: | 5052771363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2012 | ||||||||
| LastUpdateDate: | 04/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | MIKULEC | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | GRACE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 5052722325 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | PA2011-0042 | NM | Y | Hospitals | General Acute Care Hospital |
No ID Information.