1508931619 NPI number — SUTTER MEDICAL GROUP OF THE REDWOODS

Table of content: (NPI 1508931619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508931619 NPI number — SUTTER MEDICAL GROUP OF THE REDWOODS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUTTER MEDICAL GROUP OF THE REDWOODS
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:
1508931619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3883 AIRWAY DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-1670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-521-8809
Provider Business Mailing Address Fax Number:
707-521-8835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 SNYDER LN
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ROHNERT PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94928-2915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-585-8347
Provider Business Practice Location Address Fax Number:
707-585-8056
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROCKSTROH
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
707-521-8809

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR00055421 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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