Provider Demographics
NPI:1790197614
Name:UNION MEDICAL
Entity Type:Organization
Organization Name:UNION MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:
Authorized Official - Last Name:CORONA-GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-578-4815
Mailing Address - Street 1:207 N UNION AVE STE H
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 N UNION AVE STE H
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3068
Practice Address - Country:US
Practice Address - Phone:575-578-4815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0650261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24332852Medicare PIN