Healthcare Provider Details

I. General information

NPI: 1689778789
Provider Name (Legal Business Name): UNMHSC DEPARTMENT OF PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS NE
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

6465 TAYLOR MILL RD
INDEPENDENCE KY
41051-9392
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3617
  • Fax: 505-272-8699
Mailing address:
  • Phone: 859-363-4952
  • Fax: 859-363-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number StateNM

VIII. Authorized Official

Name: JAMES RUSSELL DILTS
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 505-272-4443