Provider Demographics
NPI:1225076003
Name:SAN JUAN REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SAN JUAN REGIONAL MEDICAL CENTER INC
Other - Org Name:SJRMC INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CSO
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PHILIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-609-2000
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 201
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5973
Practice Address - Country:US
Practice Address - Phone:505-609-6730
Practice Address - Fax:505-609-6749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JUAN REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-03
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Q6471Medicaid
NM000Q6471Medicaid