Basic Information
| Provider Information | |||||||||
| NPI: | 1063403129 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SONORA COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FOOTHILL PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14542 LOLLY LN | ||||||||
| Address2: | |||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953709226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095363900 | ||||||||
| FaxNumber: | 2095337696 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 PAULINE CT | ||||||||
| Address2: | |||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095325154 | ||||||||
| FaxNumber: | 2095337696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 04/02/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JAHN | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FOR FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2095365011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SONORA COMMUNITY HOSPITAL | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ZZZ52952Z | 01 | CA | BLUE CROSS/BLUE SHIELD | OTHER |