=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548474448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIGUEL PUPIALES MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 10/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4163 MONTGOMERY BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-6742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-344-7246
-----------------------------------------------------
Fax | 505-344-2666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 16680
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87191-6680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-344-7246
-----------------------------------------------------
Fax | 505-344-2666
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MIGUEL PUPIALES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 505-350-8331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 200-92
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 2000-92
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------