MEDICARE: HIGH DESERT HEMATOLOGY ONCOLOGY 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	207RH0003X	Hematology & Oncology Physician	2003-0406	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1396713095	OTHER	NM	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1801015664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGH DESERT HEMATOLOGY ONCOLOGY PC

Provider Business Mailing Address
First Line	:	460 SAINT MICHAELS DR
Second Line	:	SUITE 1204
City	:	SANTA FE
State	:	NM
Zip	:	87505-7619
Country	:	US
Telephone Number	:	801-560-1566
Fax Number	:

Provider Business Practice Location Address
First Line	:	460 SAINT MICHAELS DR
Second Line	:	SUITE 1204
City	:	SANTA FE
State	:	NM
Zip	:	87505-7619
Country	:	US
Telephone Number	:	505-983-4898
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MAURY BLITMAN
Credential	:	MD
Telephone Number	:	505-983-4898

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/10/2007

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