Healthcare Provider Details

I. General information

NPI: 1184753568
Provider Name (Legal Business Name): EISBACH FACIAL PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2007
Last Update Date: 06/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7552
US

IV. Provider business mailing address

7800 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7552
US

V. Phone/Fax

Practice location:
  • Phone: 505-332-7800
  • Fax:
Mailing address:
  • Phone: 505-332-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number3008
License Number StateNM

VIII. Authorized Official

Name: KARL JOSEPH EISBACH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-332-7800