Healthcare Provider Details

I. General information

NPI: 1558875260
Provider Name (Legal Business Name): NORTHERN NM MEDICAL MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA STREET SUITE B
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

1421 LUISA STREET SUITE 1
SANTA FE NM
87505-4073
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-8338
  • Fax: 505-982-8393
Mailing address:
  • Phone: 505-982-8338
  • Fax: 505-982-8393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2006-0456
License Number StateNM

VIII. Authorized Official

Name: MR. JOHN STANLEY CASKEY
Title or Position: MEDICAL PROVIDER/OWNER
Credential: MD
Phone: 505-982-8338