Physician Compare National (NPI:1891792636)

HEALTHCARE PROVIDER:

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1891792636
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	7012093099
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20130412000412
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	DAUTENHAHN
	Individual professional last name
Provider First Name	LAWRENCE
	Individual professional first name
Provider Middle Name	W
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	LOUISIANA STATE UNIVERSITY SCHOOL OF MEDICINE IN NEW ORLEANS
	Individual professional's medical school
Graduation Year	1988
	Individual professional's medical school graduation year
Primary Specialty	DIAGNOSTIC RADIOLOGY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	X RAY ASSOCIATES OF NEW MEXICO PC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	6709879430
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	25
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	1750 E 30TH ST
	Group Practice or individual's line 1 address
City	FARMINGTON
	Group Practice or individual's city
State	NM
	Group Practice or individual's state
Zip Code	874019020
	Group Practice or individual's zip code (9 digits when available)
Phone Number	5053270123
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	320004
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	GERALD CHAMPION REGIONAL MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	320033
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	LOS ALAMOS MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 2
Hospital Affiliation CCN 3	321308
	Medicare CCN of hospital where individual professional provides service 3
Hospital Affiliation LBN 3	CIBOLA GENERAL HOSPITAL
	Legal business name of hospital where individual professional provides service 3
Hospital Affiliation CCN 4	320005
	Medicare CCN of hospital where individual professional provides service 4
Hospital Affiliation LBN 4	SAN JUAN REGIONAL MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 4
Professional Accepts Medicare Assignment	Y