Provider Demographics
NPI:1366631616
Name:SIEVERS SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:SIEVERS SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SIEVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-226-3023
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0055
Mailing Address - Country:US
Mailing Address - Phone:575-226-3023
Mailing Address - Fax:575-226-3024
Practice Address - Street 1:304 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6218
Practice Address - Country:US
Practice Address - Phone:575-226-3023
Practice Address - Fax:575-226-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2002-0109207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH09985Medicare UPIN