1497758155 NPI number — SACRAMENTO EAR NOSE & THROAT SURGICAL & MEDICAL GROUP INC

Table of content: (NPI 1497758155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497758155 NPI number — SACRAMENTO EAR NOSE & THROAT SURGICAL & MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SACRAMENTO EAR NOSE & THROAT SURGICAL & MEDICAL GROUP 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:
SACRAMENTO EAR, NOSE, & THROAT
Provider Other Organization Name Type Code:
3
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:
1497758155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 EXPOSITION BLVD
Provider Second Line Business Mailing Address:
BLDG 700
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95815-4300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-736-3399
Provider Business Mailing Address Fax Number:
916-233-4171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 EXPOSITION BLVD
Provider Second Line Business Practice Location Address:
BLDG 700
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95815-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-736-6670
Provider Business Practice Location Address Fax Number:
916-233-4171
Provider Enumeration Date:
05/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DUDLEY
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
916-736-6670

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207YX0007X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CP5499 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0010460 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".