Healthcare Provider Details

I. General information

NPI: 1043933054
Provider Name (Legal Business Name): SAGE PRIMARY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7850 JEFFERSON ST NE STE 300
ALBUQUERQUE NM
87109-4314
US

IV. Provider business mailing address

7850 JEFFERSON ST NE STE 300
ALBUQUERQUE NM
87109-4314
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-1114
  • Fax: 505-884-3004
Mailing address:
  • Phone: 505-884-1114
  • Fax: 505-884-3004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. REUBEN SUTTER
Title or Position: CEO
Credential: MD
Phone: 505-884-1114