Provider Demographics
NPI:1497910848
Name:RIO GRANDE DERMATOLOGY, PC
Entity Type:Organization
Organization Name:RIO GRANDE DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:FRANCINE
Authorized Official - Middle Name:O
Authorized Official - Last Name:MONTANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-896-2900
Mailing Address - Street 1:4545 ALAMEDA BLVD NE
Mailing Address - Street 2:SUITE G
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1591
Mailing Address - Country:US
Mailing Address - Phone:505-896-2900
Mailing Address - Fax:505-938-4198
Practice Address - Street 1:4545 ALAMEDA BLVD NE
Practice Address - Street 2:SUITE G
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1591
Practice Address - Country:US
Practice Address - Phone:505-896-2900
Practice Address - Fax:505-938-4198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20020450207N00000X
NM20050405207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47235306Medicaid
NM76659755Medicaid
NM47235306Medicaid
NM343618003Medicare PIN
NM76659755Medicaid
NM342418100Medicare PIN