1619101912 NPI number — SUTTER WEST BAY MEDICAL FOUNDATION

Table of content: (NPI 1619101912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619101912 NPI number — SUTTER WEST BAY MEDICAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUTTER WEST BAY MEDICAL FOUNDATION
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:
6
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:
1619101912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 254947
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95865-4947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-854-6975
Provider Business Mailing Address Fax Number:
916-854-6844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3006 S MARYLAND PKWY
Provider Second Line Business Practice Location Address:
#470
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89109-2218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-796-9111
Provider Business Practice Location Address Fax Number:
702-792-9112
Provider Enumeration Date:
05/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GATES
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
RCFO
Authorized Official Telephone Number:
415-600-7755

Provider Taxonomy Codes

  • Taxonomy code: 207RI0008X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100511636 RENO , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100511635 LAS VEGAS , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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