1245411529 NPI number — NORTHERN CALIFORNIA MEDICAL ASSOC INC

Table of content: (NPI 1245411529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245411529 NPI number — NORTHERN CALIFORNIA MEDICAL ASSOC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN CALIFORNIA MEDICAL ASSOC 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:
1245411529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3536 MENDOCINO AVE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-3634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-525-6485
Provider Business Mailing Address Fax Number:
707-573-6918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 LYNCH CREEK WAY
Provider Second Line Business Practice Location Address:
STE 10
Provider Business Practice Location Address City Name:
PETALUMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94954-2355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-782-9123
Provider Business Practice Location Address Fax Number:
707-782-9622
Provider Enumeration Date:
11/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SKIDMORE
Authorized Official First Name:
RUTH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
707-573-6925

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ZZZ51563Y . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1245411529 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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