Basic Information
| Provider Information | |||||||||
| NPI: | 1285829366 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST VINCENT HOSPITAL | ||||||||
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| OtherOrganizationName: | CHRISTUS ST. VINCENT WOMEN'S CARE SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 S PACHECO ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875050504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059840303 | ||||||||
| FaxNumber: | 5059841116 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 SAINT MICHAELS DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059840303 | ||||||||
| FaxNumber: | 5059841116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 06/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | MONTOYA | ||||||||
| AuthorizedOfficialFirstName: | LILLIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5059135202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. VINCENT HOSPITAL | ||||||||
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| NPICertificationDate: | 06/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 84074043 | 05 | NM | MEDICAID |