Provider Demographics
NPI:1114977675
Name:EASTERN NEW MEXICO PHYSICIANS AND SURGEONS LLC
Entity Type:Organization
Organization Name:EASTERN NEW MEXICO PHYSICIANS AND SURGEONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-763-9800
Mailing Address - Street 1:2425 W 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:505-763-9800
Mailing Address - Fax:505-769-1998
Practice Address - Street 1:2425 W 21ST STREET
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:505-763-9800
Practice Address - Fax:505-769-1998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78904374Medicaid
NM00NM001B06OtherBCBS OF NM
NM03-07242-6000OtherCRS-1 NUMBER
NMDF1773OtherRAILROAD MEDICARE PIN
NM03-07242-6000OtherCRS-1 NUMBER
NM300521116Medicare PIN