Basic Information
| Provider Information | |||||||||
| NPI: | 1851614432 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNM MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | CENTER FOR DEVELOPMENT & DISABILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | SUITE 2222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 MENAUL BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871071851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2010 | ||||||||
| LastUpdateDate: | 03/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCCLAIN | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5052720322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 98686364 | 05 | NM | MEDICAID |