Provider Demographics
NPI:1235256447
Name:ST. VINCENT HOSPITAL
Entity Type:Organization
Organization Name:ST. VINCENT HOSPITAL
Other - Org Name:POJOAQUE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:ALEX
Authorized Official - Last Name:VALDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-913-5202
Mailing Address - Street 1:5 PETROGLYPH CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-1001
Mailing Address - Country:US
Mailing Address - Phone:505-455-1962
Mailing Address - Fax:505-455-2355
Practice Address - Street 1:5 PETROGLYPH CIR
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-1001
Practice Address - Country:US
Practice Address - Phone:505-455-1962
Practice Address - Fax:505-455-2355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG9509Medicaid
NMG9509Medicaid