Provider Demographics
NPI:1235327784
Name:GALISTEO ADVANCED GYNECOLOGY LLC
Entity Type:Organization
Organization Name:GALISTEO ADVANCED GYNECOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:505-992-3290
Mailing Address - Street 1:1691 GALISTEO ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4780
Mailing Address - Country:US
Mailing Address - Phone:505-984-2300
Mailing Address - Fax:505-988-1940
Practice Address - Street 1:1691 GALISTEO ST
Practice Address - Street 2:SUITE D
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4780
Practice Address - Country:US
Practice Address - Phone:505-984-2300
Practice Address - Fax:505-988-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82295207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46813Medicaid