Provider Demographics
NPI:1881998664
Name:DR. TOM CHILD AND ADOLESCENT MEDICINE
Entity type:Organization
Organization Name:DR. TOM CHILD AND ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVEL
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-412-3367
Mailing Address - Street 1:199 SAN ILDEFONSO RD
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2735
Mailing Address - Country:US
Mailing Address - Phone:505-412-3367
Mailing Address - Fax:
Practice Address - Street 1:LOS ALAMOS MEDICAL CENTER, 3917 WEST RD
Practice Address - Street 2:SUITE M250
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:UM
Practice Address - Phone:505-412-3367
Practice Address - Fax:505-662-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM93244208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty