Healthcare Provider Details

I. General information

NPI: 1740252519
Provider Name (Legal Business Name): EDWARD H TALIAFERRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 12/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PMG EMERGENCY MEDICINE 1101 CENTRAL SE
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1125
  • Fax: 505-841-1737
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2004-0796
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: