=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861420465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANTA FE ANESTHESIA SPECIALISTS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1631 HOSPITAL DR SUITE 110
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-983-3275
-----------------------------------------------------
Fax | 505-983-4812
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 14423
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87191-4423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-323-7200
-----------------------------------------------------
Fax | 505-323-7206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN C MULLICAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 505-983-3275
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 0603128
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------