Provider Demographics
NPI:1750688032
Name:RIO GRANDE INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:RIO GRANDE INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOODLUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-792-2636
Mailing Address - Street 1:4801 MCMAHON BLVD NW
Mailing Address - Street 2:SUITE 235
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5090
Mailing Address - Country:US
Mailing Address - Phone:505-792-2636
Mailing Address - Fax:505-234-1707
Practice Address - Street 1:4801 MCMAHON BLVD NW
Practice Address - Street 2:SUITE 235
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5090
Practice Address - Country:US
Practice Address - Phone:505-792-2636
Practice Address - Fax:505-234-1707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97251261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty