Provider Demographics
NPI:1619040268
Name:PHYSICIANS PLAZA SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:PHYSICIANS PLAZA SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:FULLERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-955-8420
Mailing Address - Street 1:1631 HOSPITAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4728
Mailing Address - Country:US
Mailing Address - Phone:505-955-8420
Mailing Address - Fax:505-955-8421
Practice Address - Street 1:1631 HOSPITAL DR STE 100
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4728
Practice Address - Country:US
Practice Address - Phone:505-955-8420
Practice Address - Fax:505-955-8421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3233261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM43937870Medicaid
NM32C0001115Medicare Oscar/Certification
NM800521172Medicare PIN