Provider Demographics
NPI:1740688548
Name:NORTHERN NEW MEXICO SURGICAL SERVICES PC
Entity type:Organization
Organization Name:NORTHERN NEW MEXICO SURGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-207-8890
Mailing Address - Street 1:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NM
Mailing Address - Zip Code:88415-0545
Mailing Address - Country:US
Mailing Address - Phone:575-374-0021
Mailing Address - Fax:
Practice Address - Street 1:300 WILSON ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-3304
Practice Address - Country:US
Practice Address - Phone:575-374-0021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0738208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty