Basic Information
| Provider Information | |||||||||
| NPI: | 1679690762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. VINCENT HOSPITAL | ||||||||
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| OtherOrganizationName: | ST VINCENT HOSPITAL SURGICAL GROUP | ||||||||
| 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: | 5058205227 | ||||||||
| FaxNumber: | 5058205440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1631 HOSPITAL DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059548720 | ||||||||
| FaxNumber: | 5059548721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 11/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | MONTOYA | ||||||||
| AuthorizedOfficialFirstName: | LILLIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5059135258 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. VINCENT REGIONAL MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | G9515 | 05 | NM | MEDICAID |