1750616512 NPI number — NORTH COAST FACULTY MEDICAL GROUP INC

Table of content: (NPI 1750616512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750616512 NPI number — NORTH COAST FACULTY MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH COAST FACULTY 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:
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:
1750616512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3883 AIRWAY DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-1670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-521-8809
Provider Business Mailing Address Fax Number:
707-521-8820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7064 CORLINE CT
Provider Second Line Business Practice Location Address:
B3
Provider Business Practice Location Address City Name:
SEBASTOPOL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95472-4528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-276-7920
Provider Business Practice Location Address Fax Number:
707-546-5334
Provider Enumeration Date:
10/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LEVENBERG
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
707-521-8879

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)





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