Provider Demographics
NPI:1518932151
Name:SAN JUAN REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SAN JUAN REGIONAL MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CSO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-609-6025
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 1:801 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5630
Practice Address - Country:US
Practice Address - Phone:505-609-2258
Practice Address - Fax:505-609-2259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00046011Medicaid
NM2252306Medicare PIN