Healthcare Provider Details

I. General information

NPI: 1902009756
Provider Name (Legal Business Name): HYPERBARIC MEDICAL CENTER OF NEW MEXICO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 BRUNN SCHOOL RD STE D E
SANTA FE NM
87505-1102
US

IV. Provider business mailing address

404 BRUNN SCHOOL RD STE D E
SANTA FE NM
87505-1102
US

V. Phone/Fax

Practice location:
  • Phone: 505-955-8560
  • Fax: 505-989-1587
Mailing address:
  • Phone: 505-955-8560
  • Fax: 505-989-1587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number97382
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number97382
License Number StateNM

VIII. Authorized Official

Name: MS. GAIL FIVERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-955-8560