Provider Demographics
NPI:1457539322
Name:STATE OF NEW MEXICO
Entity Type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:MEDICAL ASSISTANCE DIVISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-827-6207
Mailing Address - Street 1:PO BOX 2348
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2348
Mailing Address - Country:US
Mailing Address - Phone:505-827-3100
Mailing Address - Fax:
Practice Address - Street 1:2025 S PACHECO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3991
Practice Address - Country:US
Practice Address - Phone:505-827-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW MEXICO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare