Healthcare Provider Details

I. General information

NPI: 1275010985
Provider Name (Legal Business Name): MAIN STREET ANESTHESIA OF NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DR MARTIN LUTHER KING JR AVE NE
ALBUQUERQUE NM
87102-3619
US

IV. Provider business mailing address

6709 ACADEMY RD NE STE A
ALBUQUERQUE NM
87109-3363
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-8000
  • Fax:
Mailing address:
  • Phone: 505-308-3145
  • Fax: 505-308-3147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRICIA HEISCH
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 505-308-3145