Provider Demographics
NPI:1356314504
Name:GUTIERREZ MEDICAL GROUP PA
Entity Type:Organization
Organization Name:GUTIERREZ MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMERO
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:505-287-2948
Mailing Address - Street 1:1010 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2118
Mailing Address - Country:US
Mailing Address - Phone:505-287-2948
Mailing Address - Fax:505-287-5372
Practice Address - Street 1:1010 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2118
Practice Address - Country:US
Practice Address - Phone:505-287-2948
Practice Address - Fax:505-287-5372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44636Medicaid
NM44636Medicaid