Basic Information
| Provider Information | |||||||||
| NPI: | 1912119298 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST VINCENT HOSPITAL | ||||||||
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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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 PETROGLYPH CIRCLE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | POJOAQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059833361 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 01/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | VALDEZ | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | ALEX | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5059833361 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | MD2007-0167 | NM | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 2393470 | 01 | UHC | OTHER | NM002Q05 | 01 | NM | BCBS NM | OTHER | QMP000003399099 | 01 | MOLINA | OTHER | 10034175 | 01 | CIGNA/LOVELACE | OTHER | 64680541 | 05 | NM | MEDICAID |