Provider Demographics
NPI:1477859122
Name:FOUR CORNERS HEART AND LUNG INSTITUTE PC
Entity Type:Organization
Organization Name:FOUR CORNERS HEART AND LUNG INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:SPRUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-450-3851
Mailing Address - Street 1:2700 FARMINGTON AVE
Mailing Address - Street 2:BUILDING I SUITE 2
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4559
Mailing Address - Country:US
Mailing Address - Phone:505-326-3691
Mailing Address - Fax:505-327-9688
Practice Address - Street 1:2700 FARMINGTON AVE
Practice Address - Street 2:BUILDING I SUITE 2
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4559
Practice Address - Country:US
Practice Address - Phone:505-326-3691
Practice Address - Fax:505-327-9688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-27
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0311261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM86532031Medicaid
NMNM301033OtherMEDICARE PTAN
NMG84751Medicare UPIN