Healthcare Provider Details

I. General information

NPI: 1922287580
Provider Name (Legal Business Name): AMERIGROUP COMMUNITY CARE OF NEW MEXICO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PARK SQ 6565 AMERICAS PARKWAY, NE, SUITE 200
ALBUQUERQUE NM
87110-5374
US

IV. Provider business mailing address

2 PARK SQ 6565 AMERICAS PARKWAY, NE, SUITE 200
ALBUQUERQUE NM
87110-5374
US

V. Phone/Fax

Practice location:
  • Phone: 505-563-5554
  • Fax:
Mailing address:
  • Phone: 505-563-5554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number5019
License Number StateNM

VIII. Authorized Official

Name: MARC RUSSO
Title or Position: PRESIDENT
Credential:
Phone: 212-518-5250