Healthcare Provider Details

I. General information

NPI: 1255786703
Provider Name (Legal Business Name): PANGEA MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

IV. Provider business mailing address

PO BOX 8244
ROSWELL NM
88202-8244
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-2095
  • Fax: 575-208-0780
Mailing address:
  • Phone: 575-624-2095
  • Fax: 575-208-0780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2011-0547
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2011-0547
License Number StateNM

VIII. Authorized Official

Name: DR. STEVEN R BLACK
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 575-624-2095