Provider Demographics
NPI:1124111901
Name:SPINE SPORTS& PAIN MEDICINE STEVEN KIDMAN MDPC
Entity type:Organization
Organization Name:SPINE SPORTS& PAIN MEDICINE STEVEN KIDMAN MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:KIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:505-795-7370
Mailing Address - Street 1:129 LA PLACITA CIRSTEVEN KIDMAN MD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-795-7370
Mailing Address - Fax:505-795-7371
Practice Address - Street 1:11 CALLE MEDICO
Practice Address - Street 2:SUITE 2
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4705
Practice Address - Country:US
Practice Address - Phone:505-795-7370
Practice Address - Fax:505-795-7371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0557261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty