Provider Demographics
NPI:1376701359
Name:JUERGEN REBSTOCK MD PC
Entity Type:Organization
Organization Name:JUERGEN REBSTOCK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANS
Authorized Official - Middle Name:J
Authorized Official - Last Name:REBSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-257-3576
Mailing Address - Street 1:1401 SUDDERTH DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6104
Mailing Address - Country:US
Mailing Address - Phone:575-257-3576
Mailing Address - Fax:575-257-4513
Practice Address - Street 1:1401 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6104
Practice Address - Country:US
Practice Address - Phone:575-257-3576
Practice Address - Fax:575-257-4513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMB2083Medicare PIN