Basic Information
Provider Information | |||||||||
NPI: | 1124135132 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUTTER DELTA MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DELTA MEMORIAL HOSPITAL | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 742110 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900742110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8553981633 | ||||||||
FaxNumber: | 9257797258 | ||||||||
Practice Location | |||||||||
Address1: | 3901 LONE TREE WAY | ||||||||
Address2: |   | ||||||||
City: | ANTIOCH | ||||||||
State: | CA | ||||||||
PostalCode: | 945096200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9257797200 | ||||||||
FaxNumber: | 9257797258 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2006 | ||||||||
LastUpdateDate: | 12/03/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNTER | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: | TRENT | ||||||||
AuthorizedOfficialTitleorPosition: | VP SHARED SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9162978555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | N |   | Hospitals | General Acute Care Hospital |   | 282N00000X |   | CA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | ZZR00523F | 01 |   | MEDI CAL | OTHER | HSP40523F | 05 | CA |   | MEDICAID |