Santa Fe Family and Functional Medicine PC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

SANTA FE FAMILY AND FUNCTIONAL MEDICINE PC

Practice address

401 Botulph Lane
Santa Fe, NM 87505

Phone

(505) 983-8387

Fax

(505) 820-2733

NPI assigned

Nov 7, 2006

Last updated

Jul 13, 2017By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Bruce E Gollub, MD

Title

President

Phone

(505) 983-8387

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Isis Medicine Former legal business name

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1499904000000",
    "number": "1255400040",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "401 BOTULPH LANE",
            "city": "SANTA FE",
            "state": "NM",
            "postal_code": "87505",
            "telephone_number": "505-983-8387",
            "fax_number": "505-820-2733"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "401 BOTULPH LANE",
            "city": "SANTA FE",
            "state": "NM",
            "postal_code": "87505",
            "telephone_number": "505-983-8387",
            "fax_number": "505-820-2733"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SANTA FE FAMILY AND FUNCTIONAL MEDICINE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-07",
        "last_updated": "2017-07-13",
        "status": "A",
        "authorized_official_last_name": "GOLLUB",
        "authorized_official_first_name": "BRUCE",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "505-983-8387",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "49064",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Isis Medicine",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• Family Medicine Physician in Santa Fe, NM
• Providers in Santa Fe, NM by specialty
• Family Medicine Physician in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.