Provider Demographics
NPI:1003984089
Name:PRESBYTERIAN MEDICAL SERVICES
Entity Type:Organization
Organization Name:PRESBYTERIAN MEDICAL SERVICES
Other - Org Name:TEEN HEALTH CENTER SANTA FE HIGH SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-982-5565
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2267
Mailing Address - Country:US
Mailing Address - Phone:505-982-5565
Mailing Address - Fax:505-992-4990
Practice Address - Street 1:2100 YUCCA ST
Practice Address - Street 2:SANTA FE HIGH SCHOOL
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5456
Practice Address - Country:US
Practice Address - Phone:505-467-2439
Practice Address - Fax:505-467-2989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
NMCL00007506261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51672821Medicaid
NM51672821Medicaid