1043291164 NPI number — SUTTER TRACY COMMUNITY HOSPITAL

Table of content: (NPI 1043291164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043291164 NPI number — SUTTER TRACY COMMUNITY HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUTTER TRACY COMMUNITY HOSPITAL
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:
1043291164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 740152
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-0152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-398-1633
Provider Business Mailing Address Fax Number:
209-572-7772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 N TRACY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95376-3451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-835-1500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HUNTER
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
TRENT
Authorized Official Title or Position:
VP SHARED SERVICES
Authorized Official Telephone Number:
916-297-8555

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  030000105 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 0300000105 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HSP40313F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZR00313F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSC00313F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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