Healthcare Provider Details

I. General information

NPI: 1750688032
Provider Name (Legal Business Name): RIO GRANDE INTERNAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 MCMAHON BLVD NW SUITE 235
ALBUQUERQUE NM
87114-5090
US

IV. Provider business mailing address

4801 MCMAHON BLVD NW SUITE 235
ALBUQUERQUE NM
87114-5090
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-2636
  • Fax: 505-234-1707
Mailing address:
  • Phone: 505-792-2636
  • Fax: 505-234-1707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number97251
License Number StateNM

VIII. Authorized Official

Name: DR. KEVIN J GOODLUCK
Title or Position: PRESIDENT
Credential: MD
Phone: 505-792-2636