Healthcare Provider Details

I. General information

NPI: 1609653336
Provider Name (Legal Business Name): ELIZABETH MD FACIAL PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 WOLCOTT AVE NE STE A
ALBUQUERQUE NM
87109-4572
US

IV. Provider business mailing address

4100 WOLCOTT AVE NE STE A
ALBUQUERQUE NM
87109-4572
US

V. Phone/Fax

Practice location:
  • Phone: 505-855-5500
  • Fax: 505-855-5501
Mailing address:
  • Phone: 505-855-5500
  • Fax: 505-855-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH BLASBERG
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 505-855-5500