Provider Demographics
NPI:1144327172
Name:FOUR CORNERS NEPHROLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:FOUR CORNERS NEPHROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLWORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-326-6521
Mailing Address - Street 1:622 W MAPLE ST STE H
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6589
Mailing Address - Country:US
Mailing Address - Phone:505-326-6521
Mailing Address - Fax:505-325-6699
Practice Address - Street 1:622 W MAPLE ST STE H
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6589
Practice Address - Country:US
Practice Address - Phone:505-326-6521
Practice Address - Fax:505-325-6699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ311843Medicaid
NMF3805Medicaid
CO94004736Medicaid
CO94004736Medicaid
AZCQ3030Medicare PIN
NMF3805Medicaid
NMCQ3030Medicare PIN
AZZ23289Medicare PIN