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? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NM | NMB2083 | Medicare PIN |