MEDICARE: ORTHOPAEDIC SPORTS MEDICINE INSTITUTE

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	207X00000X	Orthopaedic Surgery Physician		NM

General Provider Information

NPI Number	:	1780605394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPAEDIC SPORTS MEDICINE INSTITUTE

Provider Business Mailing Address
First Line	:	4351 E LOHMAN AVE STE 200
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8260
Country	:	US
Telephone Number	:	505-532-9755
Fax Number	:	505-532-8881

Provider Business Practice Location Address
First Line	:	4351 E LOHMAN AVE STE 200
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8260
Country	:	US
Telephone Number	:	505-532-9755
Fax Number	:	505-532-8881

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KRISTINE J MARTINEZ
Credential	:
Telephone Number	:	505-532-9755

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	08/22/2020

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