Provider Demographics
NPI:1225002322
Name:DHHS,PHS,NAIHS, GALLUP INDIAN MEDICAL CENTER
Entity Type:Organization
Organization Name:DHHS,PHS,NAIHS, GALLUP INDIAN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:YAZZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-722-1000
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1310
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
9435282N00000X
311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH5670Medicaid
320061Medicare Oscar/Certification
NMH5670Medicaid