Provider Demographics
NPI:1073829198
Name:MARIE ROUSSEAU MD PC
Entity Type:Organization
Organization Name:MARIE ROUSSEAU MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-327-5336
Mailing Address - Street 1:804 E NAVAJO ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9119
Mailing Address - Country:US
Mailing Address - Phone:505-327-5336
Mailing Address - Fax:505-326-9120
Practice Address - Street 1:804 E NAVAJO ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9119
Practice Address - Country:US
Practice Address - Phone:505-327-5336
Practice Address - Fax:505-326-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09621Medicaid
NMD43287Medicare UPIN
NM535521628MMedicare PIN