MEDICARE: MEDICINE CLINIC LLC

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	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NM009390	OTHER	NM	BCBS

General Provider Information

NPI Number	:	1376722827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICINE CLINIC LLC

Provider Business Mailing Address
First Line	:	5419 N LOVINGTON HWY STE 10
Second Line	:
City	:	HOBBS
State	:	NM
Zip	:	88240-9135
Country	:	US
Telephone Number	:	505-392-8943
Fax Number	:	505-392-8960

Provider Business Practice Location Address
First Line	:	5419 N LOVINGTON HWY STE 10
Second Line	:
City	:	HOBBS
State	:	NM
Zip	:	88240-9135
Country	:	US
Telephone Number	:	505-392-8943
Fax Number	:	505-392-8960

Authorized Official
Title or Position	:	INTERNAL MEDICINE
Name	:	DR. JESUS J FONSECA
Credential	:
Telephone Number	:	505-392-8943

Provider Enumeration Date	:	11/01/2007
Last Update Date	:	10/17/2008

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