Provider Demographics
NPI:1528385127
Name:SANTA FE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SANTA FE MEDICAL GROUP, LLC
Other - Org Name:TAOS URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GURULE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-474-6097
Mailing Address - Street 1:330 UNIT C
Mailing Address - Street 2:PASEO DEL PUEBLO SUR
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:575-758-1414
Mailing Address - Fax:575-758-1474
Practice Address - Street 1:330 UNIT C
Practice Address - Street 2:PASEO DEL PUEBLO SUR
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-1414
Practice Address - Fax:575-758-1474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0796207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty