1467720888 NPI number — NORTHERN CALIFORNIA MEDICAL ASSOC INC

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 1467720888 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:
1467720888
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2012
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:
1370 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
ROHNERT PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94928-2934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-585-6110
Provider Business Practice Location Address Fax Number:
707-585-6145
Provider Enumeration Date:
12/13/2011

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: 207W00000X , 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: ZZZ69577Y . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CN8040 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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