MEDICARE: SANTA ROSA MEDICAL CLINIC

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	20020002	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	:	1922039171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA ROSA MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	533 LAKE DR
Second Line	:
City	:	SANTA ROSA
State	:	NM
Zip	:	88435
Country	:	US
Telephone Number	:	505-472-4311
Fax Number	:	505-472-4313

Provider Business Practice Location Address
First Line	:	533 LAKE DR
Second Line	:
City	:	SANTA ROSA
State	:	NM
Zip	:	88435
Country	:	US
Telephone Number	:	505-472-4311
Fax Number	:	505-472-4313

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	MR. SERGIO EDGARDO ABRIOLA
Credential	:	MD
Telephone Number	:	505-472-4311

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	08/22/2020

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Directions to “SANTA ROSA MEDICAL CLINIC ” Practice Location

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