Basic Information
| Provider Information | |||||||||
| NPI: | 1184711715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER MEDICAL GROUP OF THE REDWOODS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3883 AIRWAY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075218809 | ||||||||
| FaxNumber: | 7075218835 | ||||||||
| Practice Location | |||||||||
| Address1: | 3536 MENDOCINO AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075711280 | ||||||||
| FaxNumber: | 7075785849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROCKSTROH | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7075218809 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 207V00000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0055429 | 05 | CA | MEDICAID |