Basic Information
| Provider Information | |||||||||
| NPI: | 1396776332 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN JUAN REGIONAL MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SJRMC URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6210 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874996210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056092258 | ||||||||
| FaxNumber: | 5056092259 | ||||||||
| Practice Location | |||||||||
| Address1: | 4820 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053260459 | ||||||||
| FaxNumber: | 5053242259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5055996114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000Q6886 | 05 | NM | MEDICAID |