Healthcare Provider Details

I. General information

NPI: 1194900340
Provider Name (Legal Business Name): MARY HASBAH ROESSEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S SAINT FRANCIS DR SUITE C
SANTA FE NM
87501-2458
US

IV. Provider business mailing address

103 S SAINT FRANCIS DR SUITE C
SANTA FE NM
87501-2458
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-5667
  • Fax: 505-820-1632
Mailing address:
  • Phone: 505-988-5667
  • Fax: 505-820-1632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number89-288
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: