=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235362195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROCARE CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2009
-----------------------------------------------------
Last Update Date | 10/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 923 9TH ST SUITE A
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-6431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-439-9000
-----------------------------------------------------
Fax | 575-439-9144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 923 9TH ST SUITE A
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-6431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-439-9000
-----------------------------------------------------
Fax | 575-439-9144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MADHURI KOGANTI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 575-439-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MD2009-0573
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------