Healthcare Provider Details

I. General information

NPI: 1972913994
Provider Name (Legal Business Name): CASSIE FAIRCHILD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SOUTH VALLEY HEALTH CENTER 2001 CENTROL FAMILIAR SW
ALBUQUERQUE NM
87105-4592
US

IV. Provider business mailing address

PO BOX 912678
DENVER CO
80291-2678
US

V. Phone/Fax

Practice location:
  • Phone: 505-873-7400
  • Fax:
Mailing address:
  • Phone: 505-241-5182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2014-0350
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2017-0762
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: