Basic Information
| Provider Information | |||||||||
| NPI: | 1942339163 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNM HEALTH SCIENCES CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PSYCHIATRIC (UPC & CPC) MID-LEVEL SVC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 369 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871030369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722521 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 YALE BL VD., NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871063825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722210 | ||||||||
| FaxNumber: | 5052720052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WATT | ||||||||
| AuthorizedOfficialFirstName: | ELLA | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5052722644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | 6005 | NM | Y | Agencies | Nursing Care |
ID Information
| ID | Type | State | Issuer | Description | 50542 | 05 | NM | MEDICAID |