Healthcare Provider Details

I. General information

NPI: 1528494747
Provider Name (Legal Business Name): OTERO COUNTY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2559 MEDICAL DR SUITE G
ALAMOGORDO NM
88310-8703
US

IV. Provider business mailing address

2689 SCENIC DR
ALAMOGORDO NM
88310-8700
US

V. Phone/Fax

Practice location:
  • Phone: 575-437-8126
  • Fax:
Mailing address:
  • Phone: 575-434-1699
  • Fax: 575-434-8871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT JAMES HECKERT
Title or Position: CEO
Credential: FACHE
Phone: 575-443-7845