MEDICARE: PREMIER ANESTHESIA OF NEW MEXICO, LLP

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	207L00000X	Anesthesiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NM007G66	OTHER	NM	BLUE CROSS BLUE SHEILD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548264351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER ANESTHESIA OF NEW MEXICO, LLP

Provider Business Mailing Address
First Line	:	PO BOX 52194
Second Line	:	DEPT 987
City	:	PHOENIX
State	:	AZ
Zip	:	85072-2194
Country	:	US
Telephone Number	:	575-532-7000
Fax Number	:	575-532-7006

Provider Business Practice Location Address
First Line	:	1720 WYOMING BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-3855
Country	:	US
Telephone Number	:	505-292-9200
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TRACY GORDON
Credential	:	MD
Telephone Number	:	505-292-9200

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	06/10/2010

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