Lutheran Hospital Association of the San Luis Valley
Organization Active NPI Internal Medicine Physician · Alamosa, CO
NPI 1972556744 · NPPES record last updated Nov 24, 2020
Key facts
- NPI
- 1972556744
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- License
- 011001 (CO)
- Legal business name
- LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
- Practice address
- 2115 Stuart Ave
Alamosa, CO 81101-2269 - Phone
- (719) 589-3000
- Fax
- (719) 587-1372
- NPI assigned
- May 19, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Authorized official
- Name
- Mrs. Konnie Martin
- Title
- C.E.O.
- Phone
- (719) 587-1206
Other NPIs on the same Medicare enrollment 6
Practitioners 22
-
Amy Nicole Blakeslee, PA-C
-
Cathy McCurdy, PAC
-
Michael Gray Shell, D.O.
-
Matthew G Wark, PAC
-
Bennett Lynwood Davis, M.D.
-
Aaron David Fain, M.D.
-
Adrian Lyn Harvey Mass, M.D.
-
Brett J Huston, M.D.
-
Alisa Kathleen Johnson, M.D.
-
Derek Christopher Liston, M.D.
-
Omar Perez Rodriguez, M.D,
-
Andrew A Roth, M.D.
-
Tyler William Rust, M.D.
-
Daniel J Song, M.D.
-
Jenny L Underwood, M.D
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 06D1033005 | San Luis Valley Health - Stuart Clinic | Provider-performed microscopy | Jan 1, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CO
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031201000318 | CO | Part B Supplier - Clinic/Group Practice | 4789589094 |
Receives reassigned benefits from 230 practitioners 6 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Alamosa, CO; Monte Vista, CO; La Jara, CO; Del Norte, CO |
National Provider Directory
- Part of
- San Luis Valley Reg Med Ctr
Interoperability endpoints
- ecr@direct.slvrmc.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Chiropractor |
111N00000X | 011001 | CO | |
| Family Medicine Physician |
207Q00000X | |||
| Internal Medicine Physician |
207R00000X | 011001 | CO | Yes |
| Orthopaedic Surgery Physician |
207X00000X | |||
| Physical Medicine & Rehabilitation Physician |
208100000X | |||
| Preventive Medicine/Occupational Environmental Medicine Physician |
2083P0500X | |||
| Psychiatry Physician |
2084P0800X | |||
| Physician Assistant |
363A00000X | |||
| Nurse Practitioner |
363L00000X |
Addresses
Primary practice location
2115 Stuart Ave
Alamosa, CO 81101-2269
Mailing address
106 Blanca Ave
Alamosa, CO 81101-2340
Phone (719) 589-3000
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 11777869 | Medicaid | CO |
Other names
- San Luis Valley Health Stuart Avenue Clinic
Other providers in Alamosa, CO
- Lutheran Hospital Association of the San Luis Valley
- Lutheran Hospital Association of the San Luis Valley
- Lutheran Hospital Association of the San Luis Valley
- Lutheran Hospital Association of the San Luis Valley
- Lutheran Hospital Association of the San Luis Valley
- Emily Lutringer
- Norman G. Macleod
- Kevin Macphail
- Charmaine Madril
- Desiree Madril
All providers in Alamosa, CO · Internal Medicine Physician in Colorado
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 24, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.