Basic Information
| Provider Information | |||||||||
| NPI: | 1245438647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. VINCENT HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY PRACTICE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 465 SAINT MICHAELS DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875058602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059134710 | ||||||||
| FaxNumber: | 5059134711 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 SAINT MICHAELS DR # 240 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059881232 | ||||||||
| FaxNumber: | 5059841603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 06/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | MONTOYA | ||||||||
| AuthorizedOfficialFirstName: | LILLIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 5059135201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 48853321 | 05 | NM | MEDICAID |