Basic Information
| Provider Information | |||||||||
| NPI: | 1275711178 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOVELACE HEALTH SYSTEM LLC | ||||||||
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| OtherOrganizationName: | LOVELACE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 MARTIN LUTHER KING AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057278000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 MARTIN LUTHER KING AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057278000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARDENT LEGACY HOLDINGS, LLC | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.