Basic Information
| Provider Information | |||||||||
| NPI: | 1639334436 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER MEDICAL GROUP OF THE REDWOODS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3883 AIRWAY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075218809 | ||||||||
| FaxNumber: | 7075218835 | ||||||||
| Practice Location | |||||||||
| Address1: | 8465 OLD REDWOOD HWY | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | WINDSOR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954928090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075218809 | ||||||||
| FaxNumber: | 7075218835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEVENBERG | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, SMGR | ||||||||
| AuthorizedOfficialTelephone: | 7075218809 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZ013170Z | 01 | CA | BLUE SHIELD | OTHER | GR0091420 | 05 | CA | MEDICAID |