Healthcare Provider Details

I. General information

NPI: 1538403894
Provider Name (Legal Business Name): ST. VINCENT HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2968 RODEO PARK DR W STE 150
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

2968 RODEO PARK DR W STE 150
SANTA FE NM
87505-6351
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-5014
  • Fax: 505-982-2687
Mailing address:
  • Phone: 505-982-5014
  • Fax: 505-982-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number12-00117281
License Number StateNM

VIII. Authorized Official

Name: HOPE WADE
Title or Position: COO
Credential:
Phone: 928-607-0495