Provider Demographics
NPI:1396716643
Name:SAN MIGUEL HOSPITAL CORPORATION
Entity type:Organization
Organization Name:SAN MIGUEL HOSPITAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP FINANCE OP/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3840
Mailing Address - Street 1:104 LEGION DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4804
Mailing Address - Country:US
Mailing Address - Phone:505-426-3500
Mailing Address - Fax:505-454-9502
Practice Address - Street 1:104 LEGION DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4804
Practice Address - Country:US
Practice Address - Phone:505-426-3500
Practice Address - Fax:505-454-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3005282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM000068OtherBCBS
NM76546Medicaid
24644OtherPHP
24622OtherPHP SALUD
24622OtherPHP SALUD