Provider Demographics
NPI:1790946739
Name:UNIVERSITY OF NEW MEXICO MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:UNIVERSITY OF NEW MEXICO MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MASCIOTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-272-8950
Mailing Address - Street 1:UNM SCHOOL BASED HEALTH CTRS
Mailing Address - Street 2:MSC09 5040
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-0457
Mailing Address - Fax:505-272-2043
Practice Address - Street 1:11799 STATE HIGHWAY 14 S
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-8619
Practice Address - Country:US
Practice Address - Phone:505-281-3602
Practice Address - Fax:505-281-3602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA 2004-0048261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3A07Medicaid