NPIMap

Organization Active NPI

Presbyterian Medical Services

Doing business as Western NM Med Group Gallop

  • Federally Qualified Health Center (FQHC)
  • Gallup, NM
National Provider Identifier
1972670305
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PRESBYTERIAN MEDICAL SERVICES
Doing business as
Western NM Med Group Gallop
Practice address
610 N 5TH St
Gallup, NM 87301-5306
Phone
(505) 863-3120
Fax
(505) 863-2961
NPI assigned
Nov 29, 2006
Last updated
Jul 21, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

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

Authorized official

Name
Roberta Lee
Title
Cfo
Phone
(505) 982-5565

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NM Primary
Non-Pharmacy Dispensing Site 332900000X CL00007461 NM

Addresses

Primary practice location

610 N 5TH St
Gallup, NM 87301-5306

Mailing address

PO Box 2267
Rmacy
Santa Fe, NM 87504-2267

Other identifiers 2

IdentifierTypeStateIssuer
3209675OtherOTHER ID NUMBER
50526MedicaidNM

Other names 1

  • WESTERN NM MED GROUP GALLOP Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NM

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20101014000356 NM Part A Provider - Federally Qualified Health Center (FQHC) 2062324684 Practice locations: Gallup, NM

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1972670305. Details of each certification follow.

Federally qualified health center certification: CCN 321807

Legal name
PRESBYTERIAN MEDICAL SERVICES
Doing business as
WESTERN NEW MEXICO MEDICAL GROUP - GALLUP
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 1, 1969 in NM
Enrollment address
610 N Fifth St
Gallup, NM 87301-5306

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
32D0536067PMS Dba Western New Mexico Gallup Medical610 North 5TH Street, Gallup, NM 87301Certificate of waiverMar 31, 2028

National Provider Directory

National Provider Directory
Tax ID family
PMS Dba Roundtree Childrens' Development Services70 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 14

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 14

Locations

610 N Fifth St
Gallup, NM 87301
Phone (505) 863-3120

Ownership & related parties

All disclosed owners & managing parties 19

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Anne Liley Individual Corporate DirectorBoard Member Feb 11, 2016
Mario Atencio Individual Corporate DirectorBoard Member Mar 12, 2019
Anthony Armijo Individual Corporate DirectorBoard Member Aug 22, 2011
Steven C Hansen Individual Corporate OfficerPresident Nov 1, 2007
J Wendy Brown Individual Corporate DirectorBoard Member Feb 5, 2015
Scott Michlin Individual Corporate DirectorBoard Member Aug 22, 2011
Doug Smith Individual Corporate OfficerExecutive Vice President & Treas Aug 22, 2011
Marlene Waukazoo Individual Corporate DirectorBoard Member Nov 1, 2012
Don Daniel Individual Corporate OfficerCorporate Secretary May 2, 2014
Diane Lopez Individual Corporate OfficerVice President & Corporate Secre Aug 22, 2011
Patricia Collins Individual Corporate DirectorBoard Member May 2, 2014
Bryan Romkey Individual Corporate DirectorBoard Member Feb 5, 2015
Lillie Lewis Individual Corporate DirectorBoard Member May 2, 2013
Frank McCasland Individual Corporate DirectorBoard Member Aug 22, 2011
Melissa Sharpe Individual Corporate DirectorBoard Member Feb 5, 2015
Daniel Evans Individual Corporate DirectorBoard Member Feb 1, 2017
Susan K Smith Individual Corporate DirectorBoard Member Aug 22, 2011
Cynthia Rael-Vigil Individual Corporate DirectorBoard Member Aug 22, 2011
Kent E Mosbrucker Individual W-2 Managing EmployeeVice President of Finance Aug 31, 2018

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Santa Fe Family Health CenterSante Fe, NM, CCN 321950 Federally qualified health center 5% Or Greater Direct Ownership Interest Oct 1, 2012

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1164758400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1972670305",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2267",
            "address_2": "RMACY",
            "city": "SANTA FE",
            "state": "NM",
            "postal_code": "875042267"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "610 N 5TH ST",
            "city": "GALLUP",
            "state": "NM",
            "postal_code": "873015306",
            "telephone_number": "505-863-3120",
            "fax_number": "505-863-2961"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRESBYTERIAN MEDICAL SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-29",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "ROBERTA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "505-982-5565"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NM",
            "license": null,
            "primary": true
        },
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "NM",
            "license": "CL00007461",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OTHER ID NUMBER",
            "identifier": "3209675",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "50526",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WESTERN NM MED GROUP GALLOP",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Gallup, NM

Sources for this page

Verify at the official NPI Registry.