MEDICARE: PRIMARY CARE AND PREVENTIVE SERVICES, PC

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	207R00000X	Internal Medicine Physician	86-185	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	202006617	OTHER	NM	PRESBYTERIAN PIN
2	975291	OTHER	NM	UNITED HEALTHCARE PIN

General Provider Information

NPI Number	:	1558301903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY CARE AND PREVENTIVE SERVICES, PC

Provider Business Mailing Address
First Line	:	4710 JEFFERSON ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-2155
Country	:	US
Telephone Number	:	505-883-1259
Fax Number	:	505-883-3020

Provider Business Practice Location Address
First Line	:	4710 JEFFERSON ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-2155
Country	:	US
Telephone Number	:	505-883-1259
Fax Number	:	505-883-3020

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MATTHEW C BRYANT
Credential	:
Telephone Number	:	505-883-1259

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	02/27/2014

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