Healthcare Provider Details

I. General information

NPI: 1457619934
Provider Name (Legal Business Name): PANGEA MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 GAYE DR
ROSWELL NM
88201-3427
US

IV. Provider business mailing address

2604 GAYE DR
ROSWELL NM
88201-3427
US

V. Phone/Fax

Practice location:
  • Phone: 575-578-4548
  • Fax:
Mailing address:
  • Phone: 575-578-4548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD2011-0547
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMD2011-0547
License Number StateNM

VIII. Authorized Official

Name: STEVEN RAY BLACK
Title or Position: M.D.
Credential:
Phone: 575-578-4548