Provider Demographics
NPI:1912119298
Name:ST VINCENT HOSPITAL
Entity Type:Organization
Organization Name:ST VINCENT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:J
Authorized Official - Middle Name:ALEX
Authorized Official - Last Name:VALDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-983-3361
Mailing Address - Street 1:455 SAINT MICHAELS DR
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-820-5227
Mailing Address - Fax:
Practice Address - Street 1:5 PETROGLYPH CIRCLE
Practice Address - Street 2:SUITE A
Practice Address - City:POJOAQUE
Practice Address - State:NM
Practice Address - Zip Code:87506
Practice Address - Country:US
Practice Address - Phone:505-983-3361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0167282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
2393470OtherUHC
NMNM002Q05OtherBCBS NM
QMP000003399099OtherMOLINA
10034175OtherCIGNA/LOVELACE
NM64680541Medicaid
2393470OtherUHC