Healthcare Provider Details

I. General information

NPI: 1205164118
Provider Name (Legal Business Name): NEW MEXICO MEDICAL SURGICAL HOSPITAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2009
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E 19TH ST
ROSWELL NM
88201
US

IV. Provider business mailing address

117 E 19TH ST
ROSWELL NM
88201
US

V. Phone/Fax

Practice location:
  • Phone: 575-627-7000
  • Fax: 575-627-7007
Mailing address:
  • Phone: 575-627-7000
  • Fax: 575-627-7007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateNM

VIII. Authorized Official

Name: MR. ROBERT C TYK
Title or Position: CFO
Credential:
Phone: 575-625-3364