Healthcare Provider Details

I. General information

NPI: 1629001060
Provider Name (Legal Business Name): SOUTHWEST NEUROSURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S SCHWARTZ AVE
FARMINGTON NM
87401-5955
US

IV. Provider business mailing address

PO BOX 6210
FARMINGTON NM
87499-6210
US

V. Phone/Fax

Practice location:
  • Phone: 505-564-8076
  • Fax: 505-324-2259
Mailing address:
  • Phone: 505-324-2258
  • Fax: 505-324-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD E MAURIN III
Title or Position: OWNER
Credential:
Phone: 505-564-8073