MEDICARE: GUTIERREZ MEDICAL GROUP PA

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	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356314504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUTIERREZ MEDICAL GROUP PA

Provider Business Mailing Address
First Line	:	1010 E ROOSEVELT AVE
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2118
Country	:	US
Telephone Number	:	505-287-2948
Fax Number	:	505-287-5372

Provider Business Practice Location Address
First Line	:	1010 E ROOSEVELT AVE
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2118
Country	:	US
Telephone Number	:	505-287-2948
Fax Number	:	505-287-5372

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. MARIA ROMERO
Credential	:	RHIT
Telephone Number	:	505-287-2948

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	08/22/2020

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