Healthcare Provider Details

I. General information

NPI: 1376701359
Provider Name (Legal Business Name): JUERGEN REBSTOCK MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 SUDDERTH DR
RUIDOSO NM
88345-6104
US

IV. Provider business mailing address

1401 SUDDERTH DR
RUIDOSO NM
88345-6104
US

V. Phone/Fax

Practice location:
  • Phone: 575-257-3576
  • Fax: 575-257-4513
Mailing address:
  • Phone: 575-257-3576
  • Fax: 575-257-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: HANS J REBSTOCK
Title or Position: OWNER
Credential: MD
Phone: 575-257-3576