Stacey Dimitt, MD – Family Medicine Physician

Key facts

NPI: 1508151978
Entity type: Individual (NPI type 1)
Primary specialty: Family Medicine Physician 207Q00000X
License: 7613 (KS)
Practice address: 1423 E Roosevelt Ave
Grants, NM 87020-2245
Phone: (505) 287-6500
Fax: (505) 287-5393
NPI assigned: Jun 14, 2011
Sex: Female
Sole proprietor: No

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Cibola General Hospital Corporation Critical Access Hospital · Grants, NM · NPI 1780677039

Medicare reassignment NPD NM
Cibola General Hospital Corporation Rural Health Clinic/Center · Grants, NM · NPI 1457675266

NPD (past) FAMILY MEDICINE

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Cibola General Hospital Corporation Rural Health Clinic/Center · Grants, NM · NPI 1457675266

CMS ownership W-2 MANAGING EMPLOYEE

Medicare participation

Medicare fee-for-service enrollment: Enrolled in NM
Eligible to order & refer: Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

Facility	Type	Role	Since
Cibola Family Health Center Grants, NM · CCN 323409	Rural health clinic	W-2 Managing Employee	Jan 28, 2019

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
I20190226003342	NM	Practitioner - Family Practice Practitioner - Obstetrics/Gynecology	4486803491	Reassigns benefits to 2 organizations

National Provider Directory

Medicare enrollment (NPD): Yes
Credentials: Doctor of Medicine

State licenses

License	State	Type	Specialty
7613	KS	MD	Family Medicine Physician

Practice roles

Organization	Specialty	Status	New patients
Cibola General Hospital Corporation		Current since Jan 28, 2019	Accepting new patients
Cibola General Hospital Corporation	Family Medicine	Past	Accepting new patients

Locations

1016 E Roosevelt Ave
Grants, NM 87020
Phone (505) 287-4446

1423 E Roosevelt Ave
Grants, NM 87020
Phone (505) 287-6500

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Family Medicine Physician	207Q00000X	7613	KS	Yes

Addresses

Primary practice location

1423 E Roosevelt Ave
Grants, NM 87020-2245

Mailing address

1423 E Roosevelt Ave
Grants, NM 87020-2245
Phone (505) 287-6500

Other practice location 1

119 E Parliament St
Smith Center, KS 66967-3015
Phone (316) 962-3030

Other practice location 2

921 E Highway 36
Smith Center, KS 66967
Phone (785) 282-6834

Other providers in Grants, NM

All providers in Grants, NM · Family Medicine Physician in New Mexico

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 2, 2020. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
Provider of Services files (CMS): certification status, beds and related CCNs.
Order and Referring (CMS).
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.