Healthcare Provider Details

I. General information

NPI: 1720096852
Provider Name (Legal Business Name): NORTHSIDE FAMILY MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 PAN AMERICAN FREEWAY, NE SUITE 390
ALBUQUERQUE NM
87109-3401
US

IV. Provider business mailing address

6100 PAN AMERICAN FREEWAY, NE SUITE 390
ALBUQUERQUE NM
87109-3401
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-1805
  • Fax: 505-823-1844
Mailing address:
  • Phone: 505-823-1805
  • Fax: 505-823-1844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA91890
License Number StateNM

VIII. Authorized Official

Name: MARGARET W ROYSON
Title or Position: OWNER
Credential: DO
Phone: 505-823-1805