1639330913 NPI number — SUTTER MEDICAL GROUP OF THE REDWOODS

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 1639330913 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:
1639330913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2008
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:
5150 EAST HILL ROAD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LAKEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95453-5101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-262-5000
Provider Business Practice Location Address Fax Number:
707-262-5064
Provider Enumeration Date:
06/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEVENBERG
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
707-521-8879

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)





Copyright © 2007-2024 www.npivalidator.com