Provider Demographics
NPI:1902908015
Name:PETER BAILEY MD PA
Entity Type:Organization
Organization Name:PETER BAILEY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-623-4111
Mailing Address - Street 1:313 W COUNTRY CLUB ROAD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201
Mailing Address - Country:US
Mailing Address - Phone:575-623-4111
Mailing Address - Fax:575-623-2951
Practice Address - Street 1:313 W COUNTRY CLUB ROAD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201
Practice Address - Country:US
Practice Address - Phone:575-623-4111
Practice Address - Fax:575-623-2951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM92-5207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME2373Medicaid
A-39572Medicare UPIN