MEDICARE: LAS CRUCES FAMILY MEDICINE 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	207Q00000X	Family Medicine Physician	MD2010-0103	NM

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	:	1700197001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAS CRUCES FAMILY MEDICINE LLC

Provider Business Mailing Address
First Line	:	2930 HILLRISE DR
Second Line	:	SUITE 2
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4776
Country	:	US
Telephone Number	:	575-532-1111
Fax Number	:	575-532-1122

Provider Business Practice Location Address
First Line	:	2930 HILLRISE DR
Second Line	:	SUITE 2
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4776
Country	:	US
Telephone Number	:	575-532-1111
Fax Number	:	575-532-1122

Authorized Official
Title or Position	:	M.D./OWNER
Name	:	DR. IMRAN RAZA
Credential	:	M.D.
Telephone Number	:	575-532-1111

Provider Enumeration Date	:	07/01/2010
Last Update Date	:	04/29/2011

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