Basic Information
| Provider Information | |||||||||
| NPI: | 1467478818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOSCOPY CENTER OF SANTA ROSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 SONOMA AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954056664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075712192 | ||||||||
| FaxNumber: | 7075712194 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 SONOMA AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954056664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075712192 | ||||||||
| FaxNumber: | 7075712194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | AULD | ||||||||
| AuthorizedOfficialFirstName: | MARION | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7075712192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | AS1557 | 01 | CA | BLUE CROSS | OTHER | ZZZH49112 | 01 | CA | BLUE SHIELD | OTHER |