Basic Information
| Provider Information | |||||||||
| NPI: | 1467444711 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHERN CALIFORNIA CARDIOLOGY ASSOCIATES MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1330 21ST STREET #201 | ||||||||
| Address2: | C/O MIDTOWN FINANCIAL | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958114231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165616848 | ||||||||
| FaxNumber: | 9164479210 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 F ST | ||||||||
| Address2: | #117 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958193226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167331788 | ||||||||
| FaxNumber: | 9167331787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VETTER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9167331788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 207RC0001X | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | 207R10011X | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207UN0901X | 207UN0901X | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | 207RC0000X | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | GR0063163 | 05 | CA | MEDICAID | ZZZ075232 | 01 | CA | BLUE SHIELD OF CA | OTHER | DA7085 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | GR0063161 | 05 | CA | MEDICAID | ZZZ07524Z | 01 | CA | BLUE SHIELD OF CA | OTHER | ZZZ07522Z | 01 | CA | BLUE SHIELD OF CA | OTHER | GR0063162 | 05 | CA | MEDICAID | GR0063160 | 05 | CA | MEDICAID | GR0063164 | 05 | CA | MEDICAID | ZZZ08053Z | 01 | CA | BLUE SHIELD OF CA | OTHER | ZZZ66346Z | 01 | CA | BLUE SHIELD OF CA | OTHER | DB9095 | 01 | CA | RAILROAD MEDICARE PIN | OTHER |