=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497774574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNAL MEDICINE OF GRANTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 07/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 GREENLEAF CT
-----------------------------------------------------
City | GRANTS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87020-4235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-287-2621
-----------------------------------------------------
Fax | 505-287-5119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 GREENLEAF CT
-----------------------------------------------------
City | GRANTS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87020-4235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-287-2621
-----------------------------------------------------
Fax | 505-287-5119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. H N AUGENSTEIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 505-287-2621
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 2000-I38
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------