Healthcare Provider Details

I. General information

NPI: 1669540076
Provider Name (Legal Business Name): PRESBYTERIAN MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 01/09/2021
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 RICO ST
GALLUP NM
87301-8003
US

IV. Provider business mailing address

PO BOX 2267
SANTA FE NM
87504-2267
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-3821
  • Fax:
Mailing address:
  • Phone: 505-982-5565
  • Fax: 505-992-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number6437
License Number StateNM

VIII. Authorized Official

Name: DOUG SMITH
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 505-982-5565