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General NPI Number Information
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NPI Number | 1790197614
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Entity Type | Organization
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Legal Business Name | UNION MEDICAL
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Dates
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Enumeration Date | 05/27/2014
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Last Update Date | 05/27/2014
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Provider Practice Location Address
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Address Line | 207 N UNION AVE STE H
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City | ROSWELL
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State | NM
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Zip | 88201-3068
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Country | US
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Telephone | 575-578-4815
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Fax |
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Provider Business Mailing Address
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Address Line | 207 N UNION AVE STE H
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City | ROSWELL
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State | NM
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Zip | 88201-3068
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICAN
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Name | GONZALO CORONA-GONZALEZ
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Credential | M.D.
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Telephone | 575-578-4815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | MD2007-0650
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License Number State | NM
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