Basic Information
| Provider Information | |||||||||
| NPI: | 1851307433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANCOVIC | ||||||||
| FirstName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | SUITE 2222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7801 ACADEMY RD NE | ||||||||
| Address2: | UNM FAMILY HEALTH CLINICS, NE HEIGHTS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722700 | ||||||||
| FaxNumber: | 5052726308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 98-50 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.