Provider Demographics
NPI:1982826079
Name:PRN MEDICAL
Entity Type:Organization
Organization Name:PRN MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIELE
Authorized Official - Middle Name:
Authorized Official - Last Name:STILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-627-9350
Mailing Address - Street 1:1717 W 2ND ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-2000
Mailing Address - Country:US
Mailing Address - Phone:505-627-5700
Mailing Address - Fax:505-627-9419
Practice Address - Street 1:1717 W 2ND ST
Practice Address - Street 2:SUITE 115
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-2000
Practice Address - Country:US
Practice Address - Phone:505-627-5700
Practice Address - Fax:505-627-9419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2010-11-23
Deactivation Date:2007-11-26
Deactivation Code:
Reactivation Date:2010-10-28
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB8576Medicaid
NMG73744Medicare UPIN
NM53133Medicare ID - Type UnspecifiedMEDICARE