Provider Demographics
NPI:1710289814
Name:ST. VINCENT HOSPITAL
Entity Type:Organization
Organization Name:ST. VINCENT HOSPITAL
Other - Org Name:CHRISTUS ST. VINCENT DEVARGAS FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:TASSIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-820-5201
Mailing Address - Street 1:510 N GUADALUPE ST
Mailing Address - Street 2:SUITE C1
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-6510
Mailing Address - Country:US
Mailing Address - Phone:505-913-4660
Mailing Address - Fax:
Practice Address - Street 1:510 N GUADALUPE ST
Practice Address - Street 2:SUITE C1
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-6510
Practice Address - Country:US
Practice Address - Phone:505-913-4660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51038846Medicaid
NM100521049Medicare PIN