Healthcare Provider Details

I. General information

NPI: 1215173000
Provider Name (Legal Business Name): NEW MEXICO PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2008
Last Update Date: 12/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SAINT MICHAELS DR BUILDING 200
SANTA FE NM
87505-7619
US

IV. Provider business mailing address

460 SAINT MICHAELS DR BUILDING 200
SANTA FE NM
87505-7619
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-5551
  • Fax:
Mailing address:
  • Phone: 505-988-5551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number192RX2
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number192RX2
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number159RX2
License Number StateNM

VIII. Authorized Official

Name: DR. JONAS R. SKARDIS
Title or Position: OWNER
Credential: DOM
Phone: 505-670-5060