Healthcare Provider Details

I. General information

NPI: 1164754453
Provider Name (Legal Business Name): NEW MEXICO RHEUMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 11/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 LOUISIANA BLVD NE
ALBUQUERQUE NM
87113-2105
US

IV. Provider business mailing address

8200 LOUISIANA BLVD NE
ALBUQUERQUE NM
87113-2105
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-2400
  • Fax:
Mailing address:
  • Phone: 505-828-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD20050123
License Number StateNM

VIII. Authorized Official

Name: DR. PETER ANTHONY ROSANDICH
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 404-759-6866