Healthcare Provider Details

I. General information

NPI: 1922018712
Provider Name (Legal Business Name): PHILLIP WILLIAM CARMODY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 ACADEMY RD NE #230
ALBUQUERQUE NM
87111-1229
US

IV. Provider business mailing address

8906 BROCK LN NE
ALBUQUERQUE NM
87122-3753
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-1558
  • Fax:
Mailing address:
  • Phone: 505-858-0716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number7415
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: