Basic Information
| Provider Information | |||||||||
| NPI: | 1104194927 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER VALLEY MEDICAL FOUNDATION | ||||||||
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| OtherOrganizationName: | SUTTER MEDICAL FOUNDATION PIONEER HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2750 GATEWAY OAKS DRIVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958333658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168877398 | ||||||||
| FaxNumber: | 9165033886 | ||||||||
| Practice Location | |||||||||
| Address1: | 24685 HIGHWAY 88 | ||||||||
| Address2: | |||||||||
| City: | PIONEER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092577500 | ||||||||
| FaxNumber: | 2092577501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2011 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | HALLMARK | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9168877312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUTTER MEDICAL FOUNDATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 058502 | 05 | CA | MEDICAID |