Healthcare Provider Details

I. General information

NPI: 1598933145
Provider Name (Legal Business Name): HEAD AND NECK SURGEONS OF NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 TIJERAS AVE NE STE 22
ALBUQUERQUE NM
87106-4749
US

IV. Provider business mailing address

1020 TIJERAS AVE NE STE 22
ALBUQUERQUE NM
87106-4749
US

V. Phone/Fax

Practice location:
  • Phone: 505-848-3124
  • Fax: 505-848-8077
Mailing address:
  • Phone: 505-848-3124
  • Fax: 505-848-8077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number97-130
License Number StateNM

VIII. Authorized Official

Name: ALLYSON M RAY
Title or Position: MANAGER
Credential: M.D.
Phone: 505-848-3124