Provider Demographics
NPI:1558667873
Name:ADVANCED UROLOGY OF NEW MEXICO LLC
Entity Type:Organization
Organization Name:ADVANCED UROLOGY OF NEW MEXICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:MOURACHOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-661-8500
Mailing Address - Street 1:3917 WEST RD
Mailing Address - Street 2:SUITE 137
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2275
Mailing Address - Country:US
Mailing Address - Phone:505-661-8500
Mailing Address - Fax:505-661-0096
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:SUITE 137
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2275
Practice Address - Country:US
Practice Address - Phone:505-661-8500
Practice Address - Fax:505-661-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty