Healthcare Provider Details

I. General information

NPI: 1104971886
Provider Name (Legal Business Name): HERBERT V RACHELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ESPANOLA MULTI-SPECIALTY CLINIC 1010 SPRUCE ST
ESPANOLA NM
87532
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-0340
  • Fax: 505-367-0346
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number76-249
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number76-249
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: