Provider Demographics
NPI:1770189045
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:CBO DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:R
Authorized Official - Last Name:HIPSHER-BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-609-2258
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 1:656 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5968
Practice Address - Country:US
Practice Address - Phone:505-609-2990
Practice Address - Fax:505-609-2996
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JUAN REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty