Basic Information
| Provider Information | |||||||||
| NPI: | 1528240934 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. VINCENT HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANTA FE GERIATRICS AND INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 465 SAINT MICHAELS DR | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059464260 | ||||||||
| FaxNumber: | 5059464261 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 SAINT MICHAELS DR | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059464260 | ||||||||
| FaxNumber: | 5059464261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 03/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | VALDEZ | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | ALEX | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5058205202 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65352076 | 05 | NM | MEDICAID |