MEDICARE: BLUE SKIES PRIMARY CARE 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	207Q00000X	Family Medicine Physician		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

General Provider Information

NPI Number	:	1740321439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE SKIES PRIMARY CARE PC

Provider Business Mailing Address
First Line	:	1110 W FLORIDA ST
Second Line	:
City	:	DEMING
State	:	NM
Zip	:	88030-4908
Country	:	US
Telephone Number	:	505-546-4811
Fax Number	:	505-546-4821

Provider Business Practice Location Address
First Line	:	1110 W FLORIDA ST
Second Line	:
City	:	DEMING
State	:	NM
Zip	:	88030-4908
Country	:	US
Telephone Number	:	505-546-4811
Fax Number	:	505-546-4821

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT GRAOR
Credential	:	M.D.
Telephone Number	:	505-546-4811

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	01/28/2010

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