Provider Demographics
NPI:1295828218
Name:EASTERN PLAINS MEDICAL GROUP, P.C.
Entity type:Organization
Organization Name:EASTERN PLAINS MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-622-7593
Mailing Address - Street 1:350 W COUNTRY CLUB RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5205
Mailing Address - Country:US
Mailing Address - Phone:505-622-7593
Mailing Address - Fax:505-622-5538
Practice Address - Street 1:350 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE 205
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5205
Practice Address - Country:US
Practice Address - Phone:505-622-7593
Practice Address - Fax:505-622-5538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM89-82174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP5116Medicaid
NMP5116Medicaid