Healthcare Provider Details

I. General information

NPI: 1619902863
Provider Name (Legal Business Name): ROSWELL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

IV. Provider business mailing address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

V. Phone/Fax

Practice location:
  • Phone: 505-622-8170
  • Fax: 505-624-8751
Mailing address:
  • Phone: 505-622-8170
  • Fax: 505-624-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2002-0076
License Number StateNM

VIII. Authorized Official

Name: MR. MICHAEL PORTACCI
Title or Position: GROUP VP
Credential:
Phone: 615-465-7000