Healthcare Provider Details

I. General information

NPI: 1801830179
Provider Name (Legal Business Name): THERESA MICHELLE GENOVESE ELLIOTT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA MICHELLE GENOVESE ELLIOTT MD

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 BECKNER RD LEVEL 1 POD 2 STE 1650
SANTA FE NM
87507-0000
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-772-2000
  • Fax: 505-983-5202
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number99206
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number99-206
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: