Healthcare Provider Details

I. General information

NPI: 1235327784
Provider Name (Legal Business Name): GALISTEO ADVANCED GYNECOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 GALISTEO ST SUITE D
SANTA FE NM
87505-4780
US

IV. Provider business mailing address

1691 GALISTEO ST SUITE D
SANTA FE NM
87505-4780
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-2300
  • Fax: 505-988-1940
Mailing address:
  • Phone: 505-984-2300
  • Fax: 505-988-1940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number82295
License Number StateNM

VIII. Authorized Official

Name: BRIAN SUMMERS
Title or Position: PRACTICE MANAGER
Credential: MBA
Phone: 505-992-3290