1639334436 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 1639334436 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:
1639334436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2008
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:
8465 OLD REDWOOD HWY
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
WINDSOR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95492-8090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-521-8809
Provider Business Practice Location Address Fax Number:
707-521-8835
Provider Enumeration Date:
07/22/2008

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, SMGR
Authorized Official Telephone Number:
707-521-8809

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: ZZZ013170Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0091420 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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