Edwin Emmanuel Nebblett, MD
Individual provider Active NPI Family Medicine Physician · Reserve, NM
NPI 1558352963 · NPPES record last updated Sep 24, 2024
Key facts
- NPI
- 1558352963
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 99-267 (NM)
- Practice address
- 1 Foster Lane
Reserve, NM 87830-0710 - Phone
- (575) 533-6456
- Fax
- (575) 533-6767
- NPI assigned
- Nov 3, 2005
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 7
Hospital & facility affiliations 2
Medicare Care Compare profile
- Specialty
- Family Practice
- Education
- Loma Linda University School of Medicine, 1978
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Presbyterian Medical Services
Stallant Medical Group Inc
Practice addresses (Care Compare)
1422 Paseo de Peralta
Santa Fe, NM 87501-4391
Phone (505) 982-5565
515 E Washington Blvd
Crescent City, CA 95531-8342
Phone (707) 460-1802
Hospital & facility affiliations
- Sutter Coast Hospital
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NM, CA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20100520000338 | NM | Practitioner - Family Practice | 3173652716 | Reassigns benefits to 1 organization |
| I20180523000684 | CA | Practitioner - Family Practice | 3173652716 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| G152996 | CA | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Stallant Medical Group Inc | Current |
Accepting new patients | |
| Presbyterian Medical Services | Current | Accepting new patients | |
| Stallant Medical Group Inc | Family Medicine | Current |
Accepting new patients |
| Presbyterian Medical Services | Current |
Accepting new patients | |
| Presbyterian Medical Services | Current |
Accepting new patients | |
| Newstart Medical Group Inc | Current |
Accepting new patients | |
| Presbyterian Medical Services | Family Medicine | Past | Accepting new patients |
Locations
515 E Washington Blvd
Crescent City, CA 95531
Phone (707) 460-1802
1217 Bonita St
Grants, NM 87020
Phone (505) 287-2950
1422 Paseo de Peralta
Santa Fe, NM 87501
Phone (505) 982-5565
1300 Enterprise Rd
Socorro, NM 87801
Phone (575) 835-4444
Interoperability endpoints
- edwin.nebblett.1@33456.direct.athenahealth.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | G152996 | CA | |
| Family Medicine Physician | 207Q00000X | 99-267 | NM | Yes |
Addresses
Primary practice location
1 Foster Lane
Reserve, NM 87830-0710
Mailing address
2837 Highway 32
Quemado, NM 87829-9118
Phone (575) 313-6070
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 99-267 | Other | NM | STATE LICENSE |
Other providers in Reserve, NM
- County of Catron
- Jenifer Ann Deziel
- Troy Lee Garey
- Marcia J. Glick
- Janice L Kiehne
- Mary Jo H Shortes
- Joyce Ann Stigge
- Robert Stoops
All providers in Reserve, 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 24, 2024. 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.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.