Provider Demographics
NPI:1144966136
Name:G & M MEDICAL CENTER
Entity type:Organization
Organization Name:G & M MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC AGACNP
Authorized Official - Phone:505-415-0719
Mailing Address - Street 1:1316 JACKIE RD SE STE 500
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6607
Mailing Address - Country:US
Mailing Address - Phone:505-415-0719
Mailing Address - Fax:505-372-0093
Practice Address - Street 1:1316 JACKIE RD SE STE 400
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1045
Practice Address - Country:US
Practice Address - Phone:505-415-0719
Practice Address - Fax:505-372-0093
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:G & M MEDICAL CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-11
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM66754852Medicaid