1134139769 NPI number — SANTA ROSA MEDICAL GROUP, 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 1134139769 NPI number — SANTA ROSA MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA ROSA 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:
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:
1134139769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3661 E. LAS POSAS RD
Provider Second Line Business Mailing Address:
G162
Provider Business Mailing Address City Name:
CAMARILLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-987-5041
Provider Business Mailing Address Fax Number:
805-987-6297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3661 E. LAS POSAS RD
Provider Second Line Business Practice Location Address:
G162
Provider Business Practice Location Address City Name:
CAMARILLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-987-5041
Provider Business Practice Location Address Fax Number:
805-987-6297
Provider Enumeration Date:
08/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EILERMAN
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-987-5041

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A48615 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X , with the licence number: A61469 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RE0101X , with the licence number: G36258 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RH0003X , with the licence number: G43738 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: ZZZ16399Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".