Provider Demographics
NPI:1295811495
Name:NEW PUEBLO MEDICINE PC
Entity type:Organization
Organization Name:NEW PUEBLO MEDICINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:I
Authorized Official - Last Name:SELWYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-290-0300
Mailing Address - Street 1:6365 E TANQUE VERDE RD 120
Mailing Address - Street 2:NEW PUEBLO MEDICINE PC
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3848
Mailing Address - Country:US
Mailing Address - Phone:520-290-0300
Mailing Address - Fax:520-298-9230
Practice Address - Street 1:6365 E TANQUE VERDE RD 120
Practice Address - Street 2:NEW PUEBLO MEDICINE PC
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3848
Practice Address - Country:US
Practice Address - Phone:520-290-0300
Practice Address - Fax:520-298-9230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCN8163OtherRR MEDICARE
AZZWMBHHMedicare PIN