MEDICARE: PRESBYTERIAN MEDICAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site	CL00007401	NM
2	261QF0400X	Federally Qualified Health Center (FQHC)		NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3209687	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1205902376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESBYTERIAN MEDICAL SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 2267
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87504-2267
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1217 BONITA ST
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2103
Country	:	US
Telephone Number	:	505-287-2958
Fax Number	:	505-287-2403

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	DOUG SMITH
Credential	:
Telephone Number	:	505-982-5565

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	01/09/2021

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Directions to “PRESBYTERIAN MEDICAL SERVICES ” Practice Location

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