1265431084 NPI number — NORTHERN CALIFORNIA MEDICAL ASSOC INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265431084 NPI number — NORTHERN CALIFORNIA MEDICAL ASSOC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN CALIFORNIA MEDICAL ASSOC INC
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:
1265431084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3536 MENDOCINO AVE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-3634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-525-6485
Provider Business Mailing Address Fax Number:
707-573-6918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5108 HILL RD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95453-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-262-1840
Provider Business Practice Location Address Fax Number:
707-262-5844
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SKIDMORE
Authorized Official First Name:
RUTH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
707-573-6925

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ01768Z . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0001731 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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