Provider Demographics
NPI:1093935355
Name:UNION COUNTY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:UNION COUNTY MEDICAL CENTER INC
Other - Org Name:UNION COUNTY MEDICAL CENTER PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN WORMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-374-8313
Mailing Address - Street 1:314 N. 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NM
Mailing Address - Zip Code:88415-0565
Mailing Address - Country:US
Mailing Address - Phone:575-374-8313
Mailing Address - Fax:575-374-2064
Practice Address - Street 1:314 N. 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-0565
Practice Address - Country:US
Practice Address - Phone:575-374-8313
Practice Address - Fax:575-374-2064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000005645Medicaid
NM000045785Medicaid
NM323849Medicare Oscar/Certification
NM=========Medicare PIN