Healthcare Provider Details

I. General information

NPI: 1104935386
Provider Name (Legal Business Name): WARREN D. MCKELVY MD PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 W COUNTRY CLUB RD STE 13
ROSWELL NM
88201-5804
US

IV. Provider business mailing address

313 W COUNTRY CLUB RD STE 13
ROSWELL NM
88201-5804
US

V. Phone/Fax

Practice location:
  • Phone: 575-625-1371
  • Fax: 575-623-4400
Mailing address:
  • Phone: 575-625-1371
  • Fax: 575-623-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number77-217
License Number StateNM

VIII. Authorized Official

Name: ROB MCKELVY
Title or Position: OFFICE MANAGER
Credential:
Phone: 575-625-1371