Basic Information
| Provider Information | |||||||||
| NPI: | 1710589015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN JUAN REGIONAL MEDICAL CENTER INC | ||||||||
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| OtherOrganizationName: | SJHP FAMILY MEDICINE FARMINGTON | ||||||||
| 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: | 656 W MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874015968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056092990 | ||||||||
| FaxNumber: | 5056092996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2020 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | HIPSHER-BYRD | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CBO DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5056092258 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.