Provider Demographics
NPI:1326044512
Name:INFECTIOUS DISEASES AND INTERNAL MEDICINE
Entity Type:Organization
Organization Name:INFECTIOUS DISEASES AND INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:BACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-848-3730
Mailing Address - Street 1:5901 HARPER DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3587
Mailing Address - Country:US
Mailing Address - Phone:505-848-3730
Mailing Address - Fax:505-848-3732
Practice Address - Street 1:5901 HARPER DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3587
Practice Address - Country:US
Practice Address - Phone:505-848-3730
Practice Address - Fax:505-848-3732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78-15174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMD35990Medicare UPIN
NME12602Medicare UPIN
NMF96024Medicare UPIN
NMS94364Medicare UPIN
NME84996Medicare UPIN
NMF30206Medicare UPIN
NMC97654Medicare UPIN