Provider Demographics
NPI:1093800534
Name:SAN JUAN REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SAN JUAN REGIONAL MEDICAL CENTER INC
Other - Org Name:SAN JUAN PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CSO
Authorized Official - Prefix:
Authorized Official - First Name:J. MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-324-6025
Mailing Address - Street 1:PO BOX 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:505-609-2259
Practice Address - Street 1:407 S SCHWARTZ AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5925
Practice Address - Country:US
Practice Address - Phone:505-609-6700
Practice Address - Fax:505-609-6701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JUAN REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-03
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000S8021Medicaid