Healthcare Provider Details

I. General information

NPI: 1801129796
Provider Name (Legal Business Name): GUILHERME BROMBERG MARIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE SUITE 7600
ALBUQUERQUE NM
87106-4917
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 505-563-2500
  • Fax: 505-563-2599
Mailing address:
  • Phone: 505-923-5364
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberPENDING
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD2009-0690
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: