Provider Demographics
NPI:1083728109
Name:MIMBRES INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:MIMBRES INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-HOMSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-544-7280
Mailing Address - Street 1:122 S GOLD AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-3755
Mailing Address - Country:US
Mailing Address - Phone:575-544-7280
Mailing Address - Fax:575-544-7281
Practice Address - Street 1:122 S GOLD AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-3755
Practice Address - Country:US
Practice Address - Phone:575-544-7280
Practice Address - Fax:575-544-7281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM011036OtherBLUE CROSS BLUE SHIELD
NMA8242Medicaid
300521018Medicare ID - Type Unspecified