Provider Demographics
NPI:1821045840
Name:SAN JUAN COUNTY HOSPITAL
Entity Type:Organization
Organization Name:SAN JUAN COUNTY HOSPITAL
Other - Org Name:BLANDING MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-587-1123
Mailing Address - Street 1:735 S 200 W
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3909
Mailing Address - Country:US
Mailing Address - Phone:435-678-2254
Mailing Address - Fax:435-678-2534
Practice Address - Street 1:735 S 200 W
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3922
Practice Address - Country:US
Practice Address - Phone:435-678-2254
Practice Address - Fax:435-678-2534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005HOSP-203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000309120Medicaid
UT=========121Medicaid
UT463989Medicare Oscar/Certification