Healthcare Provider Details

I. General information

NPI: 1891027512
Provider Name (Legal Business Name): MARK EDWARD POLHEMUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 DR MARTIN LUTHER KING JR AVE NE STE 201
ALBUQUERQUE NM
87102-3667
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-3020
  • Fax: 505-727-9590
Mailing address:
  • Phone: 505-272-1476
  • Fax: 505-727-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number261872
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD2022-1151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: