1407073919 NPI number — SACRAMENTO EAR NOSE AND THROAT SURGICAL MEDICAL GROUP INC

Table of content: (NPI 1407073919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407073919 NPI number — SACRAMENTO EAR NOSE AND THROAT SURGICAL MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SACRAMENTO EAR NOSE AND THROAT SURGICAL 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:
1407073919
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:
1561 CREEKSIDE DR
Provider Second Line Business Mailing Address:
STE 180
Provider Business Mailing Address City Name:
FOLSOM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95630-3492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-984-8830
Provider Business Mailing Address Fax Number:
916-984-8834

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3810 J ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95816-5521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-736-3408
Provider Business Practice Location Address Fax Number:
916-233-4171
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUDLEY
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO ADMIN
Authorized Official Telephone Number:
916-736-3408

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com