1558446187 NPI number — SAN JUAN ONCOLOGY ASSOCIATES, PC

Table of content: (NPI 1558446187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558446187 NPI number — SAN JUAN ONCOLOGY ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN JUAN ONCOLOGY ASSOCIATES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558446187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2325 E 30TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87401-8900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-564-6850
Provider Business Mailing Address Fax Number:
505-564-6890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 E 30TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401-8900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-564-6850
Provider Business Practice Location Address Fax Number:
505-564-6890
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NEIDHART
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MD, CEO
Authorized Official Telephone Number:
505-564-6850

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RX0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PROVP23839 . This is a "CIMMARON SALUD MOLINA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 30179882 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 788664 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020403599 . This is a "ENERGY EMPLOYEES OCCU" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 700521049 . This is a "MEDICARE TRAILBLAZERS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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