Healthcare Provider Details

I. General information

NPI: 1881998664
Provider Name (Legal Business Name): DR. TOM CHILD AND ADOLESCENT MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LOS ALAMOS MEDICAL CENTER, 3917 WEST RD SUITE M250
LOS ALAMOS NM
87544
UM

IV. Provider business mailing address

199 SAN ILDEFONSO RD
LOS ALAMOS NM
87544-2735
US

V. Phone/Fax

Practice location:
  • Phone: 505-412-3367
  • Fax: 505-662-9200
Mailing address:
  • Phone: 505-412-3367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number93244
License Number StateNM

VIII. Authorized Official

Name: DR. MARVEL ELIZABETH HARRISON
Title or Position: OFFICE MANAGER
Credential: PHD
Phone: 505-412-3367