Basic Information
| Provider Information | |||||||||
| NPI: | 1235120676 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UKIAH ADVENTIST HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVENTIST HEALTH UKIAH VALLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 888867 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900888867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 275 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954824531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074637360 | ||||||||
| FaxNumber: | 7074637689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TETZ | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FO | ||||||||
| AuthorizedOfficialTelephone: | 7074637360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207K00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 282N00000X | 110000095 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP40301F | 05 | CA | MEDICAID | ZZZ13334Z | 01 | CA | BLUE SHIELD | OTHER | 050301 | 01 | CA | BLUE CROSS | OTHER | ZZZC2307Z | 01 | CA | BLUE SHIELD | OTHER | ZZZC2308Z | 01 | CA | BLUE SHIELD | OTHER | 005433002 | 01 | CA | KAISER | OTHER | 195519900 | 01 | CA | US DEPARTMENT OF LABOR | OTHER | ZZZ18251Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ92403Z | 01 | CA | BLUE SHIELD | OTHER | ZZR00301F | 05 | CA | MEDICAID |