Basic Information
| Provider Information | |||||||||
| NPI: | 1790946739 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF NEW MEXICO MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNM SCHOOL BASED HEALTH CTRS | ||||||||
| Address2: | MSC09 5040 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052720457 | ||||||||
| FaxNumber: | 5052722043 | ||||||||
| Practice Location | |||||||||
| Address1: | 11799 STATE HIGHWAY 14 S | ||||||||
| Address2: | |||||||||
| City: | TIJERAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870598619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052813602 | ||||||||
| FaxNumber: | 5052813602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | MASCIOTRA | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5052728950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | PA 2004-0048 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
| ID | Type | State | Issuer | Description | 3A07 | 05 | NM | MEDICAID |