Provider Demographics
NPI:1104903434
Name:SAN JUAN NEPHROLOGY
Entity type:Organization
Organization Name:SAN JUAN NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-541-3690
Mailing Address - Street 1:PO BOX 526
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87103-0526
Mailing Address - Country:US
Mailing Address - Phone:866-541-3690
Mailing Address - Fax:866-541-3691
Practice Address - Street 1:634 W PINON ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5915
Practice Address - Country:US
Practice Address - Phone:866-541-3690
Practice Address - Fax:866-541-3691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COSAS65104OtherCO BCBS
CO95023071Medicaid
AZ502121Medicaid
NM76102Medicaid
NM7388OtherNM BCBS
CO95023071Medicaid
UT=========006Medicaid
CH5083Medicare PIN
CO95023071Medicaid
NM76102Medicaid