Basic Information
| Provider Information | |||||||||
| NPI: | 1336347731 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. VINCENT HOSPITAL | ||||||||
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| OtherOrganizationName: | ST. VINCENT HOSPITALISTS GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059896130 | ||||||||
| FaxNumber: | 5059135408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 11/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | TASSIN | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 5059135202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 45690 | 05 | NM | MEDICAID |