Provider Demographics
NPI:1700269412
Name:ADLER MEDICAL LLC
Entity type:Organization
Organization Name:ADLER MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:505-506-4445
Mailing Address - Street 1:4241 MONTGOMERY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1081
Mailing Address - Country:US
Mailing Address - Phone:505-883-8099
Mailing Address - Fax:
Practice Address - Street 1:4241 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1081
Practice Address - Country:US
Practice Address - Phone:505-883-8099
Practice Address - Fax:505-833-8649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02214261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16984064Medicaid
NM16984064OtherMEDICARE NBR 311347YL1G