Provider Demographics
NPI:1922287580
Name:AMERIGROUP COMMUNITY CARE OF NEW MEXICO, INC.
Entity Type:Organization
Organization Name:AMERIGROUP COMMUNITY CARE OF NEW MEXICO, INC.
Other - Org Name:AMERIGROUP NEW MEXICO, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-518-5250
Mailing Address - Street 1:2 PARK SQ
Mailing Address - Street 2:6565 AMERICAS PARKWAY, NE, SUITE 200
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5374
Mailing Address - Country:US
Mailing Address - Phone:505-563-5554
Mailing Address - Fax:
Practice Address - Street 1:2 PARK SQ
Practice Address - Street 2:6565 AMERICAS PARKWAY, NE, SUITE 200
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5374
Practice Address - Country:US
Practice Address - Phone:505-563-5554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5019302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization