Basic Information
| Provider Information | |||||||||
| NPI: | 1912900754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIA ASSOCIATES OF NEW MEXICO P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 LOUISIANA BLVD NE | ||||||||
| Address2: | STE 401 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052604300 | ||||||||
| FaxNumber: | 5052604338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 CENTRAL AVE SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058411234 | ||||||||
| FaxNumber: | 5058411956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 09/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | MANNE | ||||||||
| AuthorizedOfficialFirstName: | KISHORE | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5052604300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | PT0002685 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0747917 | 05 | TX | MEDICAID | 94001930 | 05 | CO | MEDICAID | 002 | 05 | NM | MEDICAID | 51227 | 05 | NM | MEDICAID |