Provider Demographics
NPI:1093801292
Name:ROOSEVELT COUNTY SPECIAL HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:ROOSEVELT COUNTY SPECIAL HOSPITAL DISTRICT
Other - Org Name:RGH-INTERNAL MEDICINE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-359-1800
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:42121 US HWY 70
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0299
Mailing Address - Country:US
Mailing Address - Phone:575-356-6652
Mailing Address - Fax:505-226-3636
Practice Address - Street 1:42121 US HWY 70
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9357
Practice Address - Country:US
Practice Address - Phone:575-356-6652
Practice Address - Fax:505-226-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM072133V00000X
NMMD2011-0222207Q00000X
NMPA2004-0028207Q00000X
NMMD2010-0626207Q00000X
NM87-277207Q00000X
NMCNP-01941207Q00000X
NMMD2010-0558207Q00000X
NMA-1584-10207Q00000X
NMCNP00289207Q00000X
NMMD2004-0707208600000X
NMMD2004-0760208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1598750614OtherNPI
1215021696OtherNPI
1245292242OtherNPI
1780778159OtherNPI
1013046994OtherNPI
NM1013221969OtherNPI
1841242831OtherNPI
1790926814OtherNPI
NM1255641338OtherNPI
1669646006OtherNPI
1528010279OtherNPI
E75122Medicare UPIN
E09169Medicare UPIN