Healthcare Provider Details

I. General information

NPI: 1992782650
Provider Name (Legal Business Name): SANTA FE INDIAN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CERRILLOS RD
SANTA FE NM
87505-3554
US

IV. Provider business mailing address

1700 CERRILLOS RD
SANTA FE NM
87505-3554
US

V. Phone/Fax

Practice location:
  • Phone: 505-946-9264
  • Fax: 505-946-9556
Mailing address:
  • Phone: 505-946-9264
  • Fax: 505-946-9556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number89-288
License Number StateNM

VIII. Authorized Official

Name: DR. MARY HASBAH ROESSEL
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 505-946-9264