Provider Demographics
NPI:1568630374
Name:SAN JUAN SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:SAN JUAN SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROBISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-327-9694
Mailing Address - Street 1:622 W MAPLE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6590
Mailing Address - Country:US
Mailing Address - Phone:505-327-9694
Mailing Address - Fax:505-327-7524
Practice Address - Street 1:622 W MAPLE ST
Practice Address - Street 2:SUITE C
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6590
Practice Address - Country:US
Practice Address - Phone:505-327-9694
Practice Address - Fax:505-327-7524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM200521018Medicare PIN