Healthcare Provider Details

I. General information

NPI: 1366577827
Provider Name (Legal Business Name): CARDIAC CARE CONSULTANTS OF NM, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 MCMAHON BLVD, NW #115
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

4824 MCMAHON BLVD, NW #115
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-248-1800
  • Fax: 505-248-1917
Mailing address:
  • Phone: 505-248-1800
  • Fax: 505-248-1917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberPT0018282
License Number StateNM

VIII. Authorized Official

Name: MR. MICHAEL E. GURULE
Title or Position: PRESIDENT
Credential: MD
Phone: 505-248-1800