=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174911093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW MEXICO CENTER FOR MINIMALLY INVASIVE THERAPIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2014
-----------------------------------------------------
Last Update Date | 01/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4901 LANG AVE NE SUITE 202
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-4495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-227-9737
-----------------------------------------------------
Fax | 505-200-3808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4901 LANG AVE NE SUITE 202
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-4495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-227-9737
-----------------------------------------------------
Fax | 505-200-3808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO MEDICAL DIRECTOR PROVIDER
-----------------------------------------------------
Name | DR. SANDEEP RAO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 614-302-3561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | MD2014-0823
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------