Basic Information
| Provider Information | |||||||||
| NPI: | 1619101912 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUTTER WEST BAY MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUTTER PACIFIC MEDICAL FOUNDATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 254947 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958654947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168546975 | ||||||||
| FaxNumber: | 9168546844 | ||||||||
| Practice Location | |||||||||
| Address1: | 3006 S MARYLAND PKWY | ||||||||
| Address2: | #470 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891092218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027969111 | ||||||||
| FaxNumber: | 7027929112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2009 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | GATES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | RCFO | ||||||||
| AuthorizedOfficialTelephone: | 4156007755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUTTER WEST BAY MEDICAL FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0008X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 100511636 RENO | 05 | NV | MEDICAID | 100511635 LAS VEGAS | 05 | NV | MEDICAID |