| Santa Fe Family And Functional Medicine Pc | |
|
401 Botulph Lane Santa Fe NM 87505 | |
| (505) 983-8387 | |
| (505) 820-2733 |
| Full Name | Santa Fe Family And Functional Medicine Pc |
|---|---|
| Speciality | Family Medicine |
| Location | 401 Botulph Lane, Santa Fe, New Mexico |
| Authorized Official Name and Position | Bruce E Gollub (PRESIDENT) |
| Authorized Official Contact | 5059838387 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Santa Fe Family And Functional Medicine Pc 401 Botulph Lane Santa Fe NM 87505 Ph: (505) 983-8387 | Santa Fe Family And Functional Medicine Pc 401 Botulph Lane Santa Fe NM 87505 Ph: (505) 983-8387 |
| NPI Number | 1255400040 |
|---|---|
| Provider Enumeration Date | 11/07/2006 |
| Last Update Date | 07/13/2017 |
| Medicare PECOS PAC ID | 3577833110 |
|---|---|
| Medicare Enrollment ID | O20170714000875 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255400040 | NPI | - | NPPES |
| 49064 | Medicaid | NM |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Bruce E. Gollub |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1508855917 PECOS PAC ID: 0941464986 Enrollment ID: I20170714001257 |
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