MEDICARE: SPINE SPORTS& PAIN MEDICINE STEVEN KIDMAN MDPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center	MD2006-0557	NM

General Provider Information

NPI Number	:	1124111901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE SPORTS& PAIN MEDICINE STEVEN KIDMAN MDPC

Provider Business Mailing Address
First Line	:	129 LA PLACITA CIRSTEVEN KIDMAN MD
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505
Country	:	US
Telephone Number	:	505-795-7370
Fax Number	:	505-795-7371

Provider Business Practice Location Address
First Line	:	11 CALLE MEDICO
Second Line	:	SUITE 2
City	:	SANTA FE
State	:	NM
Zip	:	87505-4705
Country	:	US
Telephone Number	:	505-795-7370
Fax Number	:	505-795-7371

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	STEVEN BRUCE KIDMAN
Credential	:	M D
Telephone Number	:	505-795-7370

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/07/2014

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