Healthcare Provider Details

I. General information

NPI: 1396097002
Provider Name (Legal Business Name): SURGICAL ONCOLOGY AND GASTROINTESTINAL SURGERY CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE SUITE 202
ALBUQUERQUE NM
87109-4495
US

IV. Provider business mailing address

4901 LANG AVE NE SUITE 202
ALBUQUERQUE NM
87109-4495
US

V. Phone/Fax

Practice location:
  • Phone: 505-227-9737
  • Fax:
Mailing address:
  • Phone: 505-227-9737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2001-214
License Number StateNM

VIII. Authorized Official

Name: GLENROY HEYWOOD
Title or Position: CEO
Credential: MD
Phone: 505-362-3628