Healthcare Provider Details

I. General information

NPI: 1679865125
Provider Name (Legal Business Name): UNM MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2745
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2111
  • Fax:
Mailing address:
  • Phone: 505-272-8950
  • Fax: 505-272-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number612850
License Number StateTX

VIII. Authorized Official

Name: KATHY LAFOND
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 505-272-8950