Provider Demographics
NPI:1922039171
Name:SANTA ROSA MEDICAL CLINIC
Entity Type:Organization
Organization Name:SANTA ROSA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:EDGARDO
Authorized Official - Last Name:ABRIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-472-4311
Mailing Address - Street 1:533 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435
Mailing Address - Country:US
Mailing Address - Phone:505-472-4311
Mailing Address - Fax:505-472-4313
Practice Address - Street 1:533 LAKE DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435
Practice Address - Country:US
Practice Address - Phone:505-472-4311
Practice Address - Fax:505-472-4313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20020002207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78150728Medicaid
NM78150728Medicaid