Provider Demographics
NPI:1518063643
Name:RIO GRANDE EMERGENCY MEDICINE PA
Entity Type:Organization
Organization Name:RIO GRANDE EMERGENCY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLOUGHBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-354-5770
Mailing Address - Street 1:PO BOX 5719
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-5719
Mailing Address - Country:US
Mailing Address - Phone:706-354-5770
Mailing Address - Fax:706-354-5769
Practice Address - Street 1:2450 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5069
Practice Address - Country:US
Practice Address - Phone:706-354-5770
Practice Address - Fax:706-354-5769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78138701Medicaid
NM800521049Medicare PIN
NM78138701Medicaid