Healthcare Provider Details

I. General information

NPI: 1811915234
Provider Name (Legal Business Name): SAN JUAN REGIONAL MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 FARMINGTON AVE
FARMINGTON NM
87401-4504
US

IV. Provider business mailing address

PO BOX 844088
DALLAS TX
75284-4088
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6830
  • Fax:
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM R HIPSHER-BYRD
Title or Position: CBO DIRECTOR
Credential:
Phone: 505-609-2258