Provider Demographics
NPI:1972620102
Name:ST. VINCENT HOSPITAL
Entity Type:Organization
Organization Name:ST. VINCENT HOSPITAL
Other - Org Name:ST VINCENT CAMINO ENTRADA PEDIATRICS
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 1:2590 CAMINO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4876
Mailing Address - Country:US
Mailing Address - Phone:505-946-3233
Mailing Address - Fax:505-946-3234
Practice Address - Street 1:2590 CAMINO ENTRADA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4876
Practice Address - Country:US
Practice Address - Phone:505-946-3233
Practice Address - Fax:505-946-3234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18402020Medicaid
NM100521049Medicare PIN