Provider Demographics
NPI:1740553734
Name:PRESBYTERIAN MEDICAL SERVICES
Entity type:Organization
Organization Name:PRESBYTERIAN MEDICAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-982-5565
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2267
Mailing Address - Country:US
Mailing Address - Phone:505-982-5565
Mailing Address - Fax:505-992-4990
Practice Address - Street 1:#50 COUNTY ROAD 13
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NM
Practice Address - Zip Code:87013
Practice Address - Country:US
Practice Address - Phone:575-289-2082
Practice Address - Fax:575-289-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0000Medicaid