Healthcare Provider Details

I. General information

NPI: 1912038688
Provider Name (Legal Business Name): ALBUQUERQUE FAMILY AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL LOOP NE SUITE 209
ALBUQUERQUE NM
87109-2129
US

IV. Provider business mailing address

101 HOSPITAL LOOP NE SUITE 209
ALBUQUERQUE NM
87109-2129
US

V. Phone/Fax

Practice location:
  • Phone: 505-872-8727
  • Fax: 505-872-8728
Mailing address:
  • Phone: 505-872-8727
  • Fax: 505-872-8728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA-710-80
License Number StateNM

VIII. Authorized Official

Name: DR. ROBERT DEAN BAIR JR.
Title or Position: PRESIDENT
Credential: D.O
Phone: 505-872-8727