Basic Information
Provider Information | |||||||||
NPI: | 1609218452 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. VINCENT HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHRISTUS ST. VINCENT PLASTICS AND RECONSTRUCTION SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 455 ST MICHAELS DR | ||||||||
Address2: |   | ||||||||
City: | SANTA FE | ||||||||
State: | NM | ||||||||
PostalCode: | 875057601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059135227 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 465 SAINT MICHAELS DR | ||||||||
Address2: | SUITE 204 | ||||||||
City: | SANTA FE | ||||||||
State: | NM | ||||||||
PostalCode: | 87505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059133101 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2013 | ||||||||
LastUpdateDate: | 08/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONTOYA | ||||||||
AuthorizedOfficialFirstName: | LILLIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5059135201 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X |   | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No ID Information.