Healthcare Provider Details

I. General information

NPI: 1124111901
Provider Name (Legal Business Name): SPINE SPORTS& PAIN MEDICINE STEVEN KIDMAN MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CALLE MEDICO SUITE 2
SANTA FE NM
87505-4705
US

IV. Provider business mailing address

129 LA PLACITA CIRSTEVEN KIDMAN MD
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-795-7370
  • Fax: 505-795-7371
Mailing address:
  • Phone: 505-795-7370
  • Fax: 505-795-7371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD2006-0557
License Number StateNM

VIII. Authorized Official

Name: STEVEN BRUCE KIDMAN
Title or Position: PRESIDENT OWNER
Credential: M D
Phone: 505-795-7370