Provider Demographics
NPI:1427058510
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:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-325-5011
Mailing Address - Street 1:801 WEST MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5630
Mailing Address - Country:US
Mailing Address - Phone:505-325-5011
Mailing Address - Fax:505-609-6249
Practice Address - Street 1:801 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5630
Practice Address - Country:US
Practice Address - Phone:505-325-5011
Practice Address - Fax:505-609-6249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6291231H00000X, 282N00000X, 341600000X, 3416A0800X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No341600000XTransportation ServicesAmbulance
No3416A0800XTransportation ServicesAmbulanceAir TransportGroup - Single Specialty
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00000299Medicaid
NM320005Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
NM00000299Medicaid