Provider Demographics
NPI:1144314287
Name:ROSWELL OSTEOPATHIC MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:ROSWELL OSTEOPATHIC MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:T
Authorized Official - Last Name:BAUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-623-3311
Mailing Address - Street 1:111 W. HOBBS ST.
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203
Mailing Address - Country:US
Mailing Address - Phone:575-623-3311
Mailing Address - Fax:575-622-1273
Practice Address - Street 1:111 W. HOBBS ST.
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203
Practice Address - Country:US
Practice Address - Phone:575-623-3311
Practice Address - Fax:575-622-1273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45567Medicaid
NM45567Medicaid