Healthcare Provider Details

I. General information

NPI: 1619040268
Provider Name (Legal Business Name): PHYSICIANS PLAZA SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 HOSPITAL DR STE 100
SANTA FE NM
87505-4728
US

IV. Provider business mailing address

1631 HOSPITAL DR STE 100
SANTA FE NM
87505-4728
US

V. Phone/Fax

Practice location:
  • Phone: 505-955-8420
  • Fax: 505-955-8421
Mailing address:
  • Phone: 505-955-8420
  • Fax: 505-955-8421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number3233
License Number StateNM

VIII. Authorized Official

Name: DR. PAUL S FULLERTON
Title or Position: PRESIDENT
Credential: D.O.
Phone: 505-955-8420