Provider Demographics
NPI:1972712875
Name:PRESBYTERIAN MEDICAL SERVICES
Entity type:Organization
Organization Name:PRESBYTERIAN MEDICAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC. VP
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-982-5565
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2267
Mailing Address - Country:US
Mailing Address - Phone:505-820-3466
Mailing Address - Fax:505-992-4990
Practice Address - Street 1:608 REILLY AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2634
Practice Address - Country:US
Practice Address - Phone:505-325-8931
Practice Address - Fax:505-326-7283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCU00006339251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMD0834Medicaid