Provider Demographics
NPI:1518084128
Name:ST. VINCENT HOSPITAL
Entity Type:Organization
Organization Name:ST. VINCENT HOSPITAL
Other - Org Name:RODEO FAMILY MEDICINE
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:505-820-5227
Mailing Address - Street 1:4001 RODEO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4830
Mailing Address - Country:US
Mailing Address - Phone:505-417-8994
Mailing Address - Fax:505-473-1274
Practice Address - Street 1:4001 RODEO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4830
Practice Address - Country:US
Practice Address - Phone:505-471-8994
Practice Address - Fax:505-473-1274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
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
NM60383054Medicaid
NM100521049Medicare PIN