Healthcare Provider Details

I. General information

NPI: 1144314287
Provider Name (Legal Business Name): ROSWELL OSTEOPATHIC MEDICAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W. HOBBS ST.
ROSWELL NM
88203
US

IV. Provider business mailing address

111 W. HOBBS ST.
ROSWELL NM
88203
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-3311
  • Fax: 575-622-1273
Mailing address:
  • Phone: 575-623-3311
  • Fax: 575-622-1273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNM

VIII. Authorized Official

Name: MR. BEAU T BAUMANN
Title or Position: CEO/ADMINISTRATOR
Credential:
Phone: 575-623-3311