Provider Demographics
NPI:1972670305
Name:PRESBYTERIAN MEDICAL SERVICES
Entity Type:Organization
Organization Name:PRESBYTERIAN MEDICAL SERVICES
Other - Org Name:WESTERN NM MED GROUP GALLOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-982-5565
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:RMACY
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 N 5TH ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5306
Practice Address - Country:US
Practice Address - Phone:505-863-3120
Practice Address - Fax:505-863-2961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM261QF0400X
NMCL00007461332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
3209675OtherOTHER ID NUMBER
NM50526Medicaid
3209675OtherOTHER ID NUMBER