Provider Demographics
NPI:1548264351
Name:PREMIER ANESTHESIA OF NEW MEXICO, LLP
Entity type:Organization
Organization Name:PREMIER ANESTHESIA OF NEW MEXICO, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-292-9200
Mailing Address - Street 1:PO BOX 52194
Mailing Address - Street 2:DEPT 987
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2194
Mailing Address - Country:US
Mailing Address - Phone:575-532-7000
Mailing Address - Fax:575-532-7006
Practice Address - Street 1:1720 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3855
Practice Address - Country:US
Practice Address - Phone:505-292-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM007G66OtherBLUE CROSS BLUE SHEILD
NM78986575Medicaid
NM900521220Medicare Oscar/Certification