Provider Demographics
NPI:1609809235
Name:SAN JUAN MEDICAL GROUP PC
Entity Type:Organization
Organization Name:SAN JUAN MEDICAL GROUP PC
Other - Org Name:FARMINGTON FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-327-4867
Mailing Address - Street 1:622 W MAPLE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6590
Mailing Address - Country:US
Mailing Address - Phone:505-327-4867
Mailing Address - Fax:505-327-5355
Practice Address - Street 1:622 W MAPLE ST
Practice Address - Street 2:SUITE B
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6590
Practice Address - Country:US
Practice Address - Phone:505-327-4867
Practice Address - Fax:505-327-5355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM47359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM=========Medicare PIN