Provider Demographics
NPI:1285253682
Name:PRESBYTERIAN HEALTHCARE SERVICES
Entity type:Organization
Organization Name:PRESBYTERIAN HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:T
Authorized Official - Last Name:POLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-923-5355
Mailing Address - Street 1:PRESBYTERUAN PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 26666
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:211 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6002
Practice Address - Country:US
Practice Address - Phone:575-257-8200
Practice Address - Fax:575-630-4237
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESBYTERIAN HEALTHCARE SERVICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000521Medicaid