MEDICARE: RUSSELL CANFIELD MD PC

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

General Provider Information

NPI Number	:	1811644933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELL CANFIELD MD PC

Provider Business Mailing Address
First Line	:	66 AVENIDA ALDEA
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-9449
Country	:	US
Telephone Number	:	505-795-7111
Fax Number	:	505-795-7112

Provider Business Practice Location Address
First Line	:	66 AVENIDA ALDEA
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-9449
Country	:	US
Telephone Number	:	505-795-7111
Fax Number	:	505-795-7112

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. LAWRENCE RUSSELL CANFIELD
Credential	:	MD
Telephone Number	:	505-795-7111

Provider Enumeration Date	:	03/08/2022
Last Update Date	:	03/08/2022

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