Basic Information
Provider Information | |||||||||
NPI: | 1306238183 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOVELACE HEALTH SYSTEM, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 BURTON HILLS BLVD | ||||||||
Address2: | SUITE 250 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372156293 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6152963000 | ||||||||
FaxNumber: | 6152966227 | ||||||||
Practice Location | |||||||||
Address1: | 311 W COUNTRY CLUB RD | ||||||||
Address2: | SUITE 1 | ||||||||
City: | ROSWELL | ||||||||
State: | NM | ||||||||
PostalCode: | 882015839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5756232836 | ||||||||
FaxNumber: | 5756232841 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2015 | ||||||||
LastUpdateDate: | 05/29/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PETROVICH | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | SVP | ||||||||
AuthorizedOfficialTelephone: | 6152963000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ARDENT LEGACY HOLDINGS, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.