Provider Demographics
NPI:1093141491
Name:OTERO COUNTY MEDICAL GROUP
Entity Type:Organization
Organization Name:OTERO COUNTY MEDICAL GROUP
Other - Org Name:CHAMPION ORTHOPEADICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HECKERT
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:575-443-7845
Mailing Address - Street 1:2689 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8700
Mailing Address - Country:US
Mailing Address - Phone:575-434-1699
Mailing Address - Fax:575-434-8871
Practice Address - Street 1:2539 MEDICAL DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8720
Practice Address - Country:US
Practice Address - Phone:575-434-2116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OTERO COUNTY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty