MEDICARE: SAN JUAN ENDOSCOPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0800X	Endoscopy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558454678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JUAN ENDOSCOPY LLC

Provider Business Mailing Address
First Line	:	PO BOX 1974
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87499-1974
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	950 W PINON ST
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-5905
Country	:	US
Telephone Number	:	803-252-7979
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	GEORGE PAYNE
Credential	:	MD
Telephone Number	:	505-564-8200

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	11/14/2007

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