=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679717789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALAN MANNHEIMER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2009
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 407 S SCHWARTZ AVE STE 201
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87401-5925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-609-6700
-----------------------------------------------------
Fax | 505-609-2259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 QUAIL TRAIL UNIT B
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-208-0204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0203X
-----------------------------------------------------
Taxonomy Name | Pediatric Critical Care Medicine Physician
-----------------------------------------------------
License Number | ME114820
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2003-0483
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 0101277209
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2013-00527
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2080P0203X
-----------------------------------------------------
Taxonomy Name | Pediatric Critical Care Medicine Physician
-----------------------------------------------------
License Number | A95367
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------