Provider Demographics
NPI:1346319076
Name:INTEGRATIVE MEDICAL CENTER OF NEW MEXICO,PC
Entity Type:Organization
Organization Name:INTEGRATIVE MEDICAL CENTER OF NEW MEXICO,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-524-3720
Mailing Address - Street 1:1155 COMMERCE DR STE C
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8257
Mailing Address - Country:US
Mailing Address - Phone:575-524-3720
Mailing Address - Fax:575-524-3721
Practice Address - Street 1:1155 COMMERCE DR STE C
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8257
Practice Address - Country:US
Practice Address - Phone:575-524-3720
Practice Address - Fax:575-524-3721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79-9208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMD43045Medicare UPIN
NM100521048Medicare ID - Type Unspecified