1295729382 NPI number — EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP INC

Table of content: (NPI 1992702732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295729382 NPI number — EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE ASSOCIATES OF SEBASTOPOL 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:
1295729382
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6880 PALM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEBASTOPOL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95472-4270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-823-7628
Provider Business Mailing Address Fax Number:
707-823-1521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6880 PALM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBASTOPOL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95472-4270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-823-7628
Provider Business Practice Location Address Fax Number:
707-823-1521
Provider Enumeration Date:
09/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KHAMTHEE
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
707-823-0229

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ16441Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0083382 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05D1077728 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0083381 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0083383 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CI4202 . This is a "MEDICARE RET RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1247100001 . This is a "DMERC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ88771Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0083380 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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