Basic Information
| Provider Information | |||||||||
| NPI: | 1275805277 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACRAMENTO MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 BUSINESS PARK WAY STE 111 | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958280959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163876929 | ||||||||
| FaxNumber: | 9163876977 | ||||||||
| Practice Location | |||||||||
| Address1: | 2708 MERCANTILE DR. | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957420959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163876929 | ||||||||
| FaxNumber: | 9163876977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2012 | ||||||||
| LastUpdateDate: | 02/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | ROOT | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9163876929 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D., M.P.H. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.