Provider Demographics
NPI:1528494747
Name:OTERO COUNTY MEDICAL GROUP
Entity type:Organization
Organization Name:OTERO COUNTY MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HECKERT
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:575-443-7845
Mailing Address - Street 1:2689 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8700
Mailing Address - Country:US
Mailing Address - Phone:575-434-1699
Mailing Address - Fax:575-434-8871
Practice Address - Street 1:2559 MEDICAL DR
Practice Address - Street 2:SUITE G
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8703
Practice Address - Country:US
Practice Address - Phone:575-437-8126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OTERO COUNTY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-SurgicalGroup - Multi-Specialty