Provider Demographics
NPI:1760038350
Name:ST JUDE MEDICAL CENTER CORP
Entity Type:Organization
Organization Name:ST JUDE MEDICAL CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:UYAMA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-309-8936
Mailing Address - Street 1:400 GOLD AVE SW STE 220
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3278
Mailing Address - Country:US
Mailing Address - Phone:682-309-8936
Mailing Address - Fax:
Practice Address - Street 1:400 GOLD AVE SW STE 220
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3278
Practice Address - Country:US
Practice Address - Phone:682-309-8936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-10
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty