1396716643 NPI number — SAN MIGUEL HOSPITAL CORPORATION

Table of content: (NPI 1396716643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396716643 NPI number — SAN MIGUEL HOSPITAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN MIGUEL HOSPITAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ALTA VISTA REGIONAL HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396716643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 LEGION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87701-4804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-426-3500
Provider Business Mailing Address Fax Number:
505-454-9502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 LEGION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87701-4804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-426-3500
Provider Business Practice Location Address Fax Number:
505-454-9502
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
SVP FINANCE OP/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-221-3840

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  3005 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NM000068 . This is a "BCBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 76546 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24644 . This is a "PHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 24622 . This is a "PHP SALUD" identifier . This identifiers is of the category "OTHER".




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