Basic Information
| Provider Information | |||||||||
| NPI: | 1225077225 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUTTER HEALTH SACRAMENTO SIERRA REGION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUTTER ROSEVILLE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160727 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958160727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167338306 | ||||||||
| FaxNumber: | 9067338396 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167811000 | ||||||||
| FaxNumber: | 9167811210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRADY | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9167811201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 05D0683935 | CA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1225077225 | 01 | CA | MEDI-CAL | OTHER |