Provider Demographics
NPI:1952471443
Name:DEPARTMENT OF STATE HEALTH SERVICES
Entity Type:Organization
Organization Name:DEPARTMENT OF STATE HEALTH SERVICES
Other - Org Name:EL PASO PSYCHIATRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIDA-FRAGOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-532-2202
Mailing Address - Street 1:4615 ALAMEDA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2702
Mailing Address - Country:US
Mailing Address - Phone:915-532-2202
Mailing Address - Fax:915-534-5587
Practice Address - Street 1:4615 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2702
Practice Address - Country:US
Practice Address - Phone:915-532-2202
Practice Address - Fax:915-534-5587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3970283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF86951Medicare UPIN
TX89343FMedicare ID - Type Unspecified