Basic Information
| Provider Information | |||||||||
| NPI: | 1598882797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. VINCENT HOSPITAL | ||||||||
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| OtherOrganizationName: | ALAN ROGERS, MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058208227 | ||||||||
| FaxNumber: | 5058205440 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 HARKLE RD SUITE A | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059836911 | ||||||||
| FaxNumber: | 5059837212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 12/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | CARLA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5058205227 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14943 | 01 | MOLINA | OTHER | NM002A08 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 45690 | 05 | NM | MEDICAID | 10001164 | 01 | LOVELACE HEALTHCARE | OTHER |