Basic Information
| Provider Information | |||||||||
| NPI: | 1518052794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRISCOLL | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 121 EL PASO RD | ||||||||
| Address2: | LINCOLN COUNTY MEDICAL COMPLEX | ||||||||
| City: | RUIDOSO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883456033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756308350 | ||||||||
| FaxNumber: | 5756305232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 10/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 86034 | NM | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 37044 | 05 | NM | MEDICAID |