=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396097002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL ONCOLOGY AND GASTROINTESTINAL SURGERY CONSULTANTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2012
-----------------------------------------------------
Last Update Date | 11/19/2013
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | GLENROY HEYWOOD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 505-362-3628
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 2001-214
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------