Basic Information
| Provider Information | |||||||||
| NPI: | 1508052572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER MEDICAL GROUP OF THE REDWOODS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15620 HEALDSBURG AVE | ||||||||
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| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954489617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074734531 | ||||||||
| FaxNumber: | 7074734559 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 STEELE LN | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075764800 | ||||||||
| FaxNumber: | 7075764825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7074734531 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.