Provider Demographics
NPI:1275545782
Name:SEREDOWYCH, MARK GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:GEORGE
Last Name:SEREDOWYCH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1650 HOSPITAL DR
Mailing Address - Street 2:SUITE 800
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4769
Mailing Address - Country:US
Mailing Address - Phone:505-395-3050
Mailing Address - Fax:505-982-5003
Practice Address - Street 1:1650 HOSPITAL DR
Practice Address - Street 2:SUITE 800
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4769
Practice Address - Country:US
Practice Address - Phone:505-395-3011
Practice Address - Fax:505-982-5003
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2015-08-18
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Provider Licenses
StateLicense IDTaxonomies
NM2000-89207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB4686Medicaid
NMB4686Medicaid
NM$$$$$$$$$Medicare PIN