Provider Demographics
NPI:1558558726
Name:SOUTHERN NEW MEXICO NEUROSURGERY LLC
Entity Type:Organization
Organization Name:SOUTHERN NEW MEXICO NEUROSURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-522-1974
Mailing Address - Street 1:PO BOX 13668
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-3668
Mailing Address - Country:US
Mailing Address - Phone:575-522-1974
Mailing Address - Fax:575-522-5209
Practice Address - Street 1:3850 E LOHMAN AVE STE C
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8288
Practice Address - Country:US
Practice Address - Phone:575-522-1974
Practice Address - Fax:575-522-5209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21709751Medicaid
DG08655OtherRR MEDICARE
NMNM007L05OtherBCBS OF NM
NMNM007L05OtherBCBS OF NM
6074090001Medicare NSC